| NPI | 1982600524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN LD1848000) |
| Additional Taxonomies | 152WC0802X Optometrist, Corneal and Contact Management (Licence: MN LD1848000) |
| Enumeration Date | 2005-06-27 |
| Last Update Date | 2010-07-26 |