| NPI | 1922333913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR 3595AT) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 3274) |
| Enumeration Date | 2009-10-08 |
| Last Update Date | 2015-06-08 |