Organization
BRODHEAD VISION CLINIC, INC
Active
Other names
Brodhead Vision
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DOUGLAS KELLEY OD (OWNER/OD)
(608) 897-2128
Entity
Organization
Contact information
Practice address
1005 17TH STREET, BRODHEAD, WI 53520
(608) 897-2128
(608) 897-3937
Mailing address
1005 17TH STREET, PO BOX 0137, BRODHEAD, WI 53520
(608) 897-2128
(608) 897-3937
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1483-035
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
38545800
—
WI
01
—
MERCYCARE
PRUDHGEN
WI
01
—
PHYSICIANS PLUS
1006622
WI
01
—
RAILROAD MEDICARE
410035917
WI
Enumeration date
09/06/2005
Last updated
10/08/2014
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