| NPI | 1760628788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3183) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 3145-035) |
| Enumeration Date | 2008-12-22 |
| Last Update Date | 2016-01-12 |