| NPI | 1679096812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KY 2080DT) |
| Additional Taxonomies | 152WV0400X Optometrist, Vision Therapy (Licence: KY 2080DT) |
| Enumeration Date | 2017-07-19 |
| Last Update Date | 2025-02-21 |