| NPI | 1609874536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IA 1597DPAT) |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Equipment, not the service) |
| Enumeration Date | 2005-07-13 |
| Last Update Date | 2012-07-10 |