Provider Demographics
NPI:1083453534
Name:MCMULLIN, RYLEY JACK (LICENSED OPTICIAN)
Entity type:Individual
Prefix:
First Name:RYLEY
Middle Name:JACK
Last Name:MCMULLIN
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3865 PALM ISLAND CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-6572
Mailing Address - Country:US
Mailing Address - Phone:435-590-0238
Mailing Address - Fax:
Practice Address - Street 1:5200 S FORT APACHE RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-1722
Practice Address - Country:US
Practice Address - Phone:702-367-2272
Practice Address - Fax:702-367-2787
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV474156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician