| NPI | 1912759309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CA 36099) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR ATI4720) |
| Enumeration Date | 2024-04-01 |
| Last Update Date | 2025-08-06 |