| NPI | 1679711675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KY 1771) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 5910) |
| Enumeration Date | 2009-01-28 |
| Last Update Date | 2020-01-24 |