| NPI | 1720464878 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IA 111912) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: LA 1800-734AT) |
| Enumeration Date | 2015-07-30 |
| Last Update Date | 2022-11-25 |