| NPI | 1861706509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NE 1353) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO 2796) |
| Enumeration Date | 2010-08-05 |
| Last Update Date | 2021-07-22 |