| NPI | 1922419738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT002865) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 6276) |
| Enumeration Date | 2014-05-14 |
| Last Update Date | 2023-02-23 |