| NPI | 1720399157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 2141) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 002488) |
| 152W00000X Optometrist (Licence: NC 2228) | |
| Enumeration Date | 2010-06-30 |
| Last Update Date | 2024-03-01 |