1568494466 NPI number — ST. MARYS DEAN VENTURES INC.

Table of content: (NPI 1568494466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568494466 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:
DAVIS DUEHR DEAN REGIONAL EYE CLINICS
Provider Other Organization Name Type Code:
3
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:
1568494466
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:
1626 TUTTLE ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
BARABOO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53913-1501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-356-2020
Provider Business Mailing Address Fax Number:
608-356-6787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1626 TUTTLE ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
BARABOO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53913-1501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-356-2020
Provider Business Practice Location Address Fax Number:
608-356-6787
Provider Enumeration Date:
07/07/2006

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: 261QM1300X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QS0132X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 38715000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38715900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38720000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38723700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38711700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38719500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38710800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38720600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38611600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38714900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38715600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21257000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38718300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38715400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38718200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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