| NPI | 1477746295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100493) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA 00004098) |
| Enumeration Date | 2007-08-24 |
| Last Update Date | 2021-03-23 |