| NPI | 1518232149 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3415) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VT 0000000) |
| Enumeration Date | 2012-03-15 |
| Last Update Date | 2018-04-10 |