| NPI | 1639593908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152WV0400X Optometrist Vision Therapy (Licence: IL 046010924) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901004791) |
| Enumeration Date | 2014-02-07 |
| Last Update Date | 2021-03-16 |