| NPI | 1649230947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 6702T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO T03284) |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2007-07-08 |