| NPI | 1871517805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1414) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT002306) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2019-11-13 |