| NPI | 1770031452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MT OPT-OPT-LIC-2799) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP-100378) |
| Enumeration Date | 2016-09-12 |
| Last Update Date | 2017-02-23 |