Provider Demographics
NPI:1730654385
Name:RYAN PETERSON OD, INC.
Entity Type:Organization
Organization Name:RYAN PETERSON OD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-299-6200
Mailing Address - Street 1:936 BARONET DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-8016
Mailing Address - Country:US
Mailing Address - Phone:702-683-4481
Mailing Address - Fax:
Practice Address - Street 1:5691 RICKENBACKER RD
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-7052
Practice Address - Country:US
Practice Address - Phone:702-644-6671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty