| NPI | 1528517695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 9390T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ 2147) |
| Enumeration Date | 2016-09-29 |
| Last Update Date | 2021-11-03 |