Healthcare Provider Details

I. General information

NPI: 1417993072
Provider Name (Legal Business Name): ST. MARYS DEAN VENTURES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215B CHURCH ST
MONTELLO WI
53949-9763
US

IV. Provider business mailing address

215B CHURCH ST
MONTELLO WI
53949-9763
US

V. Phone/Fax

Practice location:
  • Phone: 608-297-2501
  • Fax: 608-297-2648
Mailing address:
  • Phone: 608-297-2501
  • Fax: 608-297-2648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateWI

VIII. Authorized Official

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