| NPI | 1649588708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1640) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 3192-35) |
| Enumeration Date | 2010-09-22 |
| Last Update Date | 2016-04-07 |