Provider Demographics
NPI:1033954599
Name:DR. RYAN AMBROSE, PLLC
Entity type:Organization
Organization Name:DR. RYAN AMBROSE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-295-5154
Mailing Address - Street 1:6761 E KELTON LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5645
Mailing Address - Country:US
Mailing Address - Phone:262-295-5154
Mailing Address - Fax:
Practice Address - Street 1:3870 W HAPPY VALLEY RD STE 150
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-3296
Practice Address - Country:US
Practice Address - Phone:623-362-8642
Practice Address - Fax:623-561-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1558711507OtherINDIVIDUAL NPI