| NPI | 1710984109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WV 782-OD) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 618002978) |
| Enumeration Date | 2005-06-30 |
| Last Update Date | 2022-02-17 |