| NPI | 1861477754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO TO3227) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1610) |
| Enumeration Date | 2005-12-13 |
| Last Update Date | 2011-08-02 |