| NPI | 1801279898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004912) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: FL OPC5132) |
| Enumeration Date | 2015-07-08 |
| Last Update Date | 2019-03-14 |