| NPI | 1790707040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 7357T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1758) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2010-06-08 |