| NPI | 1578627139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WI 1577-035) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 1683) |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2012-03-14 |