| NPI | 1447237326 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WI 2187-035) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN MN2254) |
| Enumeration Date | 2005-12-30 |
| Last Update Date | 2016-02-22 |