| NPI | 1770025298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2500) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618002539) |
| Enumeration Date | 2016-11-15 |
| Last Update Date | 2019-11-25 |