| NPI | 1386639110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: LA 809097T) |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Equipment, not the service) (Licence: LA 152W00000X) |
| Enumeration Date | 2005-09-19 |
| Last Update Date | 2008-12-16 |