1295788065 NPI number — SHOPKO STORES OPERATING CO. LLC

Table of content: (NPI 1295788065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295788065 NPI number — SHOPKO STORES OPERATING CO. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOPKO STORES OPERATING CO. LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHOPKO OPTICAL 109
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295788065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4060 RIVERDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84405-1518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-392-4300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4060 RIVERDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERDALE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84405-1518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-392-4300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BETTIGA
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official Telephone Number:
920-429-4297

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 410985054-408 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 014109 . This is a "VIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: UT04871 . This is a "NORIDIAN SUBMITTER ID" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 42510 . This is a "DAVIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 17932 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000090125 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: CP2230-48 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".




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