| NPI | 1710984067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 2061TG) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX MN0265923) |
| Enumeration Date | 2005-07-01 |
| Last Update Date | 2011-08-08 |