| NPI | 1619979630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WV 1004OS) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 5261T2167) |
| 152W00000X Optometrist (Licence: TN 2282) | |
| 152W00000X Optometrist (Licence: KY 1533DT) | |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2010-03-25 |