| NPI | 1407929169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: RI ODTG00497) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 3729) |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2017-02-26 |