| NPI | 1891986121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 1787) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO 2007018525) |
| 152W00000X Optometrist (Licence: NE 1280) | |
| Enumeration Date | 2007-08-01 |
| Last Update Date | 2015-08-26 |