| NPI | 1902973415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MT 697) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD00003914) |
| Enumeration Date | 2006-11-29 |
| Last Update Date | 2011-03-09 |