| NPI | 1689142770 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NE 1528) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 9562T) |
| Enumeration Date | 2018-11-06 |
| Last Update Date | 2021-10-26 |