| NPI | 1689748915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100103) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 5840T) |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2007-07-08 |