| NPI | 1740365212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TN OD0000002574) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WV 616D) |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2008-04-18 |