| NPI | 1639103799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AL S774TA431) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AL S774-TA-431) |
| Enumeration Date | 2006-07-11 |
| Last Update Date | 2021-08-31 |