| NPI | 1801889167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 11403) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO T02174) |
| Enumeration Date | 2005-08-23 |
| Last Update Date | 2011-12-20 |