| NPI | 1902581739 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NY ORT009949) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH OPT.007209) |
| Enumeration Date | 2023-06-20 |
| Last Update Date | 2024-08-11 |