| NPI | 1649848235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TN OD3686) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618003018) |
| Enumeration Date | 2021-06-11 |
| Last Update Date | 2023-06-02 |