| NPI | 1396742698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: LA 1216-377T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: LA 1216-377AT) |
| Enumeration Date | 2005-06-30 |
| Last Update Date | 2024-11-15 |