Healthcare Provider Details

I. General information

NPI: 1104914316
Provider Name (Legal Business Name): TARA RANSDELL OD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7727 W DEER VALLEY RD STE E200
PEORIA AZ
85382-2116
US

IV. Provider business mailing address

21121 N 63RD DR
GLENDALE AZ
85308-6349
US

V. Phone/Fax

Practice location:
  • Phone: 623-376-9070
  • Fax: 623-376-9079
Mailing address:
  • Phone: 623-328-7859
  • Fax: 623-376-9079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1278
License Number StateAZ

VIII. Authorized Official

Name: DR. TARA RANSDELL
Title or Position: OWNER
Credential: OD
Phone: 623-376-9070