| NPI | 1821473422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC5117) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO OPT3245) |
| Enumeration Date | 2015-07-23 |
| Last Update Date | 2020-07-02 |