| NPI | 1639202211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CT 3.002873) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 4914) |
| Enumeration Date | 2007-03-13 |
| Last Update Date | 2020-07-13 |