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General NPI Number Information
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NPI Number | 1164416236
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Entity Type | Organization
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Legal Business Name | BRODHEAD VISION CLINIC, INC
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Dates
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Enumeration Date | 09/06/2005
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Last Update Date | 10/08/2014
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Provider Practice Location Address
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Address Line | 1005 17TH STREET
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City | BRODHEAD
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State | WI
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Zip | 53520
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Country | US
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Telephone | 608-897-2128
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Fax | 608-897-3937
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Provider Business Mailing Address
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Address Line | 1005 17TH STREET PO BOX 0137
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City | BRODHEAD
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State | WI
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Zip | 53520
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Country | US
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Telephone | 608-897-2128
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Fax | 608-897-3937
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Authorized Official
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Title or Position | OWNER/OD
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Name | MR. DOUGLAS KELLEY
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Credential | OD
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Telephone | 608-897-2128
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1483-035
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License Number State | WI
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