| NPI | 1770004392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO OPT.0003328) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP-100420) |
| Enumeration Date | 2017-07-05 |
| Last Update Date | 2022-06-08 |