| NPI | 1699872846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 1288) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WY 301T) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2007-07-08 |