Brodhead Vision Clinic, Inc

Primary specialty

OptometristTaxonomy code 152W00000X

License

1483-035 Issued in WI

Legal business name

BRODHEAD VISION CLINIC, INC

Doing business as

Brodhead Vision

Practice address

1005 17TH Street
Brodhead, WI 53520

Phone

(608) 897-2128

Fax

(608) 897-3937

NPI assigned

Sep 6, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Douglas Kelley, ODNPI 1033376090

Title

Owner/OD

Phone

(608) 897-2128

Specialties & licenses 1

Addresses

Other identifiers 4

Other names 1

• Brodhead Vision Doing business as

Medicare fee-for-service enrollment

Enrolled in WI

Enrollment records 1

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Douglas Edward Kelley, OD

  • Optometrist
  • Beloit, WI
  • NPI 1033376090
  Medicare reassignment NPD Authorized official
• Kristopher L Glanville, O.D.

  • Optometrist
  • Madison, WI
  • NPI 1104825017
  NPD (past)
• Kristin L Moseman, O.D.

  • Optometrist
  • Fort Atkinson, WI
  • NPI 1912219445
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1125964800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1412726400000",
    "number": "1164416236",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1005 17TH STREET",
            "address_2": "PO BOX 0137",
            "city": "BRODHEAD",
            "state": "WI",
            "postal_code": "53520",
            "telephone_number": "608-897-2128",
            "fax_number": "608-897-3937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1005 17TH STREET",
            "city": "BRODHEAD",
            "state": "WI",
            "postal_code": "53520",
            "telephone_number": "608-897-2128",
            "fax_number": "608-897-3937"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BRODHEAD VISION CLINIC, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-06",
        "last_updated": "2014-10-08",
        "status": "A",
        "authorized_official_last_name": "KELLEY",
        "authorized_official_first_name": "DOUGLAS",
        "authorized_official_title_or_position": "OWNER/OD",
        "authorized_official_telephone_number": "608-897-2128",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "WI",
            "license": "1483-035",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "410035917",
            "identifier": "RAILROAD MEDICARE",
            "state": "WI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38545800",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "1006622",
            "identifier": "PHYSICIANS PLUS",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRUDHGEN",
            "identifier": "MERCYCARE",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Brodhead Vision",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Daniel R Branson, D.D.S.
• Brodhead Area Emergency Medical (Brodhead Area EMS)
• Brodhead Chiropractic Center LLC
• Brodhead Chiropractic Center, LLC
• Brodhead Family Chiropractic LLC
• Cheryl Buroker
• Candid Counseling LLC
• Cardinal Chiropractic LLC (Wilke Chiropractic Office)
• Robert C Cates Sr., MD
• Jeshua Michael Delorme, DC

• Optometrist in Brodhead, WI
• Providers in Brodhead, WI by specialty
• Optometrist in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.