| NPI | 1770868820 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IA 074027) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 3413) |
| Enumeration Date | 2011-10-19 |
| Last Update Date | 2017-12-05 |