| NPI | 1720196553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00003258) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 2563ATI) |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2018-10-02 |