1457304024 NPI number — SHOPKO STORES OPERATING CO. LLC

Table of content: (NPI 1457304024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457304024 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 059
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:
1457304024
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:
1001 HIGHWAY 15 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56031-4456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-238-9490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 HIGHWAY 15 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56031-4456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-238-9490
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2006

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: 35469 . This is a "AVESIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: CP2230-19 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03092036205 . This is a "MN MA PRIMEWEST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 36058 . This is a "MN HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42493 . This is a "DAVIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 014059 . This is a "VIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 17830 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C159SH . This is a "MN MA FIRST PLAN OF MN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3C391SH . This is a "MN MA FIRST PLAN OF MN" identifier . This identifiers is of the category "OTHER".




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