Provider Demographics
NPI:1194247015
Name:RYAN PETERSON O.D., INC.
Entity type:Organization
Organization Name:RYAN PETERSON O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-299-6200
Mailing Address - Street 1:4401 E SUNSET RD STE 4
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2200
Mailing Address - Country:US
Mailing Address - Phone:702-299-6200
Mailing Address - Fax:702-331-4533
Practice Address - Street 1:6370 W FLAMINGO RD STE 8
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-2275
Practice Address - Country:US
Practice Address - Phone:702-331-0777
Practice Address - Fax:877-832-5115
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RYAN PETERSON O.D.,INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty