| NPI | 1609226034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901005586) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 2032) |
| Enumeration Date | 2016-06-16 |
| Last Update Date | 2023-05-09 |