Healthcare Provider Details

I. General information

NPI: 1255288577
Provider Name (Legal Business Name): BRYAN RAMIREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 191 AND HOSPITAL DRIVE
CHINLE AZ
86503
US

IV. Provider business mailing address

22465 BROKEN LANCE CT
APPLE VALLEY CA
92307-3791
US

V. Phone/Fax

Practice location:
  • Phone: 928-674-7001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4202
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: