Healthcare Provider Details

I. General information

NPI: 1912748492
Provider Name (Legal Business Name): RYDER ELDER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 IRON BRIDGE RD
CHESTERFIELD VA
23832-6601
US

IV. Provider business mailing address

900 TERMINAL PL APT 402
RICHMOND VA
23220-1998
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-4877
  • Fax: 804-796-9168
Mailing address:
  • Phone: 804-731-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003418
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: