Provider Demographics
NPI:1568494466
Name:ST. MARYS DEAN VENTURES INC.
Entity Type:Organization
Organization Name:ST. MARYS DEAN VENTURES INC.
Other - Org Name:DAVIS DUEHR DEAN REGIONAL EYE CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-260-3586
Mailing Address - Street 1:1626 TUTTLE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1501
Mailing Address - Country:US
Mailing Address - Phone:608-356-2020
Mailing Address - Fax:608-356-6787
Practice Address - Street 1:1626 TUTTLE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1501
Practice Address - Country:US
Practice Address - Phone:608-356-2020
Practice Address - Fax:608-356-6787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARYS DEAN VENTURES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-07
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QM1300X, 261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38715000Medicaid
WI38715900Medicaid
WI38720000Medicaid
WI38723700Medicaid
WI38711700Medicaid
WI38719500Medicaid
WI38710800Medicaid
WI38720600Medicaid
WI38611600Medicaid
WI38714900Medicaid
WI38715600Medicaid
WI21257000Medicaid
WI38718300Medicaid
WI38715400Medicaid
WI38718200Medicaid
WI38715000Medicaid
WI38715900Medicaid
WI38723700Medicaid
WI38711700Medicaid