| NPI | 1821167354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 1100-2) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO 002314) |
| 152W00000X Optometrist (Licence: MA 2652) | |
| Enumeration Date | 2006-11-07 |
| Last Update Date | 2008-07-07 |