| NPI | 1689772204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA 2392) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA 2196) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2007-07-08 |