| NPI | 1568565349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WI 2800) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: FL TPOP110) |
| Enumeration Date | 2006-09-06 |
| Last Update Date | 2023-03-06 |