| NPI | 1952092595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA OPT5613) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: RI ODTG00739) |
| Enumeration Date | 2023-05-16 |
| Last Update Date | 2023-12-05 |