| NPI | 1578564522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 1264-3) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1264-2) |
| Enumeration Date | 2005-08-02 |
| Last Update Date | 2011-11-05 |