| NPI | 1578129078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: RI ODTG0676) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 5346) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-05-10 |
| Last Update Date | 2020-07-20 |