Provider Demographics
NPI:1134292378
Name:CANTON FAMILY VISION CLINIC, PC
Entity Type:Organization
Organization Name:CANTON FAMILY VISION CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TOSO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-987-2841
Mailing Address - Street 1:109 E 5TH ST
Mailing Address - Street 2:BOX 39
Mailing Address - City:CANTON
Mailing Address - State:SD
Mailing Address - Zip Code:57013-1731
Mailing Address - Country:US
Mailing Address - Phone:605-987-2841
Mailing Address - Fax:605-987-2810
Practice Address - Street 1:109 E 5TH ST
Practice Address - Street 2:BOX 39
Practice Address - City:CANTON
Practice Address - State:SD
Practice Address - Zip Code:57013-1731
Practice Address - Country:US
Practice Address - Phone:605-987-2841
Practice Address - Fax:605-987-2810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDDN8075Medicare PIN
SD40061Medicare PIN
SD40061Medicare PIN