| NPI | 1811127525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2154) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WV 1065-OD) |
| Enumeration Date | 2009-07-16 |
| Last Update Date | 2010-12-01 |