| NPI | 1366538886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 1095-3) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO 002312) |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2008-01-28 |