| Name | Value |
|---|---|
| PROVIDER TYPE | Eye and Vision Services |
| CLASSIFICATION | Optometrist |
| AREA OF SPECIALIZATION | Contact Lens |
| STATUS | Inactive |
| DATE INACTIVATED | 2005-11-15 00:00:00 |
| VA CODE | V060801 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252591 |
| EFFECTIVE DATE/TIME |
|