Provider Demographics
NPI:1710960349
Name:SOUTHTOWN VISION INC
Entity Type:Organization
Organization Name:SOUTHTOWN VISION INC
Other - Org Name:STERLING OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-394-1128
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-0162
Mailing Address - Country:US
Mailing Address - Phone:585-394-1128
Mailing Address - Fax:585-394-6877
Practice Address - Street 1:3333 W HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-3543
Practice Address - Country:US
Practice Address - Phone:585-424-5970
Practice Address - Fax:585-424-5973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8812OtherBLUE CROSS BLUE SHIELD
NY8812OtherBLUE CROSS BLUE SHIELD