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General NPI Number Information
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NPI Number | 1992899967
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Entity Type | Organization
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Legal Business Name | CANTON VISION CENTER, INC.
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 04/14/2015
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Provider Practice Location Address
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Address Line | 3221 ODONNELL ST
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City | BALTIMORE
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State | MD
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Zip | 21224-5040
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Country | US
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Telephone | 410-534-2015
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Fax | 410-534-2019
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Provider Business Mailing Address
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Address Line | 3221 ODONNELL ST
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City | BALTIMORE
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State | MD
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Zip | 21224-5040
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Country | US
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Telephone | 410-534-2015
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Fax | 410-534-2019
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. RYAN QUENTIN BEVERIDGE
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Credential | O.D.
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Telephone | 410-534-2015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TA 1553
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License Number State | MD
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