| NPI | 1407953508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH 5689) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1747) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2007-11-13 |