| NPI | 1700994944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NM 2328) |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Licence: NM 2328) |
| Enumeration Date | 2006-08-28 |
| Last Update Date | 2007-07-09 |