| NPI | 1528355872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CA 14277 TGL) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG002482) |
| Enumeration Date | 2011-07-07 |
| Last Update Date | 2015-08-11 |