Provider Demographics
NPI:1710921838
Name:ST. MARYS DEAN VENTURES INC.
Entity Type:Organization
Organization Name:ST. MARYS DEAN VENTURES INC.
Other - Org Name:POYNETTE FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:POYNETTE
Mailing Address - State:WI
Mailing Address - Zip Code:53955-0097
Mailing Address - Country:US
Mailing Address - Phone:608-635-4343
Mailing Address - Fax:608-635-7094
Practice Address - Street 1:237 W SEWARD ST
Practice Address - Street 2:
Practice Address - City:POYNETTE
Practice Address - State:WI
Practice Address - Zip Code:53955-9584
Practice Address - Country:US
Practice Address - Phone:608-635-4343
Practice Address - Fax:608-635-7094
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARYS DEAN VENTURES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-16
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32829800Medicaid
WI137082533OtherOFFICE OF WORKERS COMP
WIM13OtherDEAN HEALTH INSURANCE
WI=========016OtherTRICARE
WI32829800Medicaid
WI=========016OtherTRICARE
WICD8126Medicare ID - Type UnspecifiedRAILROAD MEDICARE