| NPI | 1740762806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2018024709) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 2203) |
| Enumeration Date | 2018-09-05 |
| Last Update Date | 2024-07-22 |