| NPI | 1386959104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 2789) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NE 1347) |
| Enumeration Date | 2010-08-17 |
| Last Update Date | 2015-04-17 |