| NPI | 1699719112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VT 30-0000233) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NH 0464) |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2020-06-10 |