| NPI | 1437401775 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3453) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KY 1988DT) |
| Enumeration Date | 2012-10-10 |
| Last Update Date | 2020-09-29 |