| NPI | 1598771768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AL S-703-TA-360) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT001312) |
| Enumeration Date | 2006-07-31 |
| Last Update Date | 2011-04-08 |