| NPI | 1609925692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WI 1956) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 1954) |
| Enumeration Date | 2007-01-09 |
| Last Update Date | 2007-07-09 |