| NPI | 1639741531 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NV 1144) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 123594249934) |
| Enumeration Date | 2021-07-12 |
| Last Update Date | 2022-11-09 |