| NPI | 1518373646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT002824) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 8815T) |
| Enumeration Date | 2014-07-09 |
| Last Update Date | 2020-12-07 |