| NPI | 1629483268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 1976) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO 2014018719) |
| Enumeration Date | 2014-06-23 |
| Last Update Date | 2021-05-05 |