| NPI | 1790858306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ND 380) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 2474) |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2008-01-23 |