| NPI | 1710063953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AL S357TA046) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT000791) |
| Enumeration Date | 2006-10-31 |
| Last Update Date | 2013-12-19 |