| NPI | 1740330539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 1262) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1311) |
| 152W00000X Optometrist (Licence: AL S-636) | |
| Enumeration Date | 2007-01-12 |
| Last Update Date | 2021-12-15 |