Provider Demographics
NPI:1558478453
Name:DICKMAN KETTLER & BRUNER INC
Entity Type:Organization
Organization Name:DICKMAN KETTLER & BRUNER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JILLYNN
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-678-3016
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:201 S SECOND ST
Mailing Address - City:COLDWATER
Mailing Address - State:OH
Mailing Address - Zip Code:45828-0095
Mailing Address - Country:US
Mailing Address - Phone:419-678-3016
Mailing Address - Fax:419-678-8849
Practice Address - Street 1:201 S 2ND ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:OH
Practice Address - Zip Code:45828-1747
Practice Address - Country:US
Practice Address - Phone:419-678-3016
Practice Address - Fax:419-678-8849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0611190Medicaid
OH9314121Medicare PIN
OH0611190Medicaid