1417993072 NPI number — ST. MARYS DEAN VENTURES INC.

Table of content: (NPI 1417993072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417993072 NPI number — ST. MARYS DEAN VENTURES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. MARYS DEAN VENTURES 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:
1417993072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215B CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTELLO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53949-9763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-297-2501
Provider Business Mailing Address Fax Number:
608-297-2648

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215B CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTELLO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53949-9763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-297-2501
Provider Business Practice Location Address Fax Number:
608-297-2648
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRINNELL
Authorized Official First Name:
AMY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICE
Authorized Official Telephone Number:
608-260-3586

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , 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: 38715400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 556775 . This is a "DEAN HEALTH INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 137082509 . This is a "OFFICE OF WORKERS COMP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 14699 . This is a "NATIONAL VISION ADMINISTR" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 20385 . This is a "SPECTERA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 054014 . This is a "VISION INS PLAN OF AMERIC" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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