| NPI | 1619318367 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CT 2904) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1773) |
| Enumeration Date | 2013-07-10 |
| Last Update Date | 2016-06-10 |