| NPI | 1982748158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA 1524) |
| Additional Taxonomies | 156FX1800X Technician/Technologist Optician (Licence: GA 410) |
| Enumeration Date | 2007-02-19 |
| Last Update Date | 2007-07-08 |