| NPI | 1962497644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL 0PC1433) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 02569TG) |
| Enumeration Date | 2005-09-19 |
| Last Update Date | 2011-07-22 |