Provider Demographics
NPI:1164416236
Name:BRODHEAD VISION CLINIC, INC
Entity Type:Organization
Organization Name:BRODHEAD VISION CLINIC, INC
Other - Org Name:BRODHEAD VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OD
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:608-897-2128
Mailing Address - Street 1:1005 17TH STREET
Mailing Address - Street 2:PO BOX 0137
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520
Mailing Address - Country:US
Mailing Address - Phone:608-897-2128
Mailing Address - Fax:608-897-3937
Practice Address - Street 1:1005 17TH STREET
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520
Practice Address - Country:US
Practice Address - Phone:608-897-2128
Practice Address - Fax:608-897-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1483-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIRAILROAD MEDICAREOther410035917
WI38545800Medicaid
WIPHYSICIANS PLUSOther1006622
WIMERCYCAREOtherPRUDHGEN
WIRAILROAD MEDICAREOther410035917
WIT63036Medicare UPIN
WI0467680001Medicare NSC
WIWI1948Medicare PIN
WI38545800Medicaid