| NPI | 1710239058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA 60816211) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA 15418) |
| Enumeration Date | 2012-10-10 |
| Last Update Date | 2018-06-11 |