| NPI | 1821403528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD 60631287TX) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA 14931TLG) |
| Enumeration Date | 2014-06-23 |
| Last Update Date | 2016-11-11 |