Provider Demographics
NPI:1588785679
Name:DEAN RETAIL SERVICES, INC.
Entity type:Organization
Organization Name:DEAN RETAIL SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT-FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-260-3586
Mailing Address - Street 1:1808 W BELTLINE HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2334
Mailing Address - Country:US
Mailing Address - Phone:608-294-6218
Mailing Address - Fax:608-250-1384
Practice Address - Street 1:225 CHURCH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1801
Practice Address - Country:US
Practice Address - Phone:608-877-2710
Practice Address - Fax:608-877-2792
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEAN HEALTH SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332H00000X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI384-41-200Medicaid
WI384-41-200Medicaid