| NPI | 1912567876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3743) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 9673) |
| Enumeration Date | 2019-06-13 |
| Last Update Date | 2026-07-28 |