| NPI | 1528158664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CA 10435) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901003734) |
| 152W00000X Optometrist (Licence: FL OPC 3532) | |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2012-03-12 |