| NPI | 1487969002 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IA 2508) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NE 1357) |
| Enumeration Date | 2010-08-09 |
| Last Update Date | 2021-11-22 |