| NPI | 1780104000 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2022005213) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 091373) |
| Enumeration Date | 2017-06-27 |
| Last Update Date | 2022-03-28 |