| NPI | 1356930630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT003325) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA OPT34786TLG) |
| Enumeration Date | 2021-01-12 |
| Last Update Date | 2021-06-23 |