| NPI | 1417992553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AK 249T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 3145AT) |
| 152W00000X Optometrist (Licence: WY 299T) | |
| Enumeration Date | 2006-06-20 |
| Last Update Date | 2017-10-04 |