| NPI | 1457808719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100529) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NV 889) |
| Enumeration Date | 2016-09-04 |
| Last Update Date | 2021-06-22 |