Healthcare Provider Details

I. General information

NPI: 1568494466
Provider Name (Legal Business Name): ST. MARYS DEAN VENTURES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 TUTTLE ST SUITE 1
BARABOO WI
53913-1501
US

IV. Provider business mailing address

1626 TUTTLE ST SUITE 1
BARABOO WI
53913-1501
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-2020
  • Fax: 608-356-6787
Mailing address:
  • Phone: 608-356-2020
  • Fax: 608-356-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number StateWI

VIII. Authorized Official

Name: AMY J GRINNELL
Title or Position: CHIEF FINANCIAL OFFICE
Credential:
Phone: 608-260-3586