| NPI | 1457367419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ME OPT724) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT001081) |
| Enumeration Date | 2006-07-31 |
| Last Update Date | 2010-10-26 |