| NPI | 1689675159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KY 979DT) |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Equipment, not the service) (Licence: KY KY979DT) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2011-09-16 |