| NPI | 1750398145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OK 2479) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901004372) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2014-12-30 |