| NPI | 1558780973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004826) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 5330001155) |
| Enumeration Date | 2014-04-14 |
| Last Update Date | 2014-06-06 |