| NPI | 1811909476 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NE 1001) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 02128) |
| Enumeration Date | 2006-08-12 |
| Last Update Date | 2007-07-09 |