| NPI | 1871606293 |
|---|---|
| Former Name | KENNETH TRAVIS PACK LAFAYETTE |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR OR 2729T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA WA OD00003720) |
| Enumeration Date | 2006-08-17 |
| Last Update Date | 2007-07-08 |