| NPI | 1619957024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NM NM489) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NM 489) |
| Enumeration Date | 2006-01-20 |
| Last Update Date | 2011-10-10 |