| NPI | 1639818578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 0003776) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AK 245605) |
| Enumeration Date | 2022-05-31 |
| Last Update Date | 2025-12-04 |