1710543228 NPI number — SHOPTIKAL LLC

Table of content: JENNIFER CRYSTAL NELSON LICSW (NPI 1265045645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710543228 NPI number — SHOPTIKAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOPTIKAL 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:
Provider Other Organization Name Type Code:
6
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:
1710543228
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19060
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54307-9060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2360 COSTCO WAY STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54311-9210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-468-4642
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STEINHORST
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
Authorized Official Title or Position:
EVP & CFO
Authorized Official Telephone Number:
920-429-7489

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; 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)