| NPI | 1538145057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 1210) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD60288309) |
| Enumeration Date | 2005-12-16 |
| Last Update Date | 2014-06-16 |