| NPI | 1982799094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 1995) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID odp-1023) |
| 152W00000X Optometrist (Licence: WA 3469) | |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2020-10-29 |