| NPI | 1588067706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004840) |
| Additional Taxonomies | 152WC0802X Optometrist Corneal and Contact Management (Licence: MI 4901004840) |
| 152WS0006X Optometrist Sports Vision (Licence: MI 4901004840) | |
| Enumeration Date | 2014-10-01 |
| Last Update Date | 2023-08-22 |