| NPI | 1760637409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3227) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 3162-035) |
| Enumeration Date | 2008-11-21 |
| Last Update Date | 2013-01-31 |