| NPI | 1407967623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ND 581) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 2579) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2013-03-18 |