| NPI | 1700105608 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CA 15195) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618002135) |
| Enumeration Date | 2010-05-18 |
| Last Update Date | 2015-05-29 |