| NPI | 1780663765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901002483) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IN 18002196) |
| Enumeration Date | 2006-01-10 |
| Last Update Date | 2010-07-02 |