1174575500 NPI number — SHOPKO STORES OPERATING CO. LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174575500 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 4017
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:
1174575500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4161 2ND ST S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56301-3761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-253-5994
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4161 2ND ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56301-3761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-253-5994
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2006

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: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42601 . This is a "DAVIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 014017 . This is a "VIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 77166SH . This is a "MN MA FIRST PLAN OF MN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 17821 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2123169 . This is a "MN MA MEDICA CHOICE CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 23667 . This is a "MN HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: CP2230-22 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35585 . This is a "AVESIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 77168MA . This is a "MN BLUE PLUS CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03092036202 . This is a "MN MA PRIMEWEST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35479 . This is a "AVESIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 410985054-4017 . This is a "NATIONAL VISION ADMIN." identifier . This identifiers is of the category "OTHER".




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