1164416236 NPI number — BRODHEAD VISION CLINIC, INC

Table of content: (NPI 1164416236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164416236 NPI number — BRODHEAD VISION CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRODHEAD VISION CLINIC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164416236
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 17TH STREET
Provider Second Line Business Mailing Address:
PO BOX 0137
Provider Business Mailing Address City Name:
BRODHEAD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-897-2128
Provider Business Mailing Address Fax Number:
608-897-3937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 17TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRODHEAD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-897-2128
Provider Business Practice Location Address Fax Number:
608-897-3937
Provider Enumeration Date:
09/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/OD
Authorized Official Telephone Number:
608-897-2128

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1483-035 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RAILROAD MEDICARE . This is a "410035917" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38545800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: PHYSICIANS PLUS . This is a "1006622" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: MERCYCARE . This is a "PRUDHGEN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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