| NPI | 1518950898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO T02290) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1373) |
| Enumeration Date | 2005-08-23 |
| Last Update Date | 2008-05-01 |