1407807118 NPI number — SHOPKO STORES OPERATING CO LLC

Table of content: LISA DIANE IUCCI DO (NPI 1275975161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407807118 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:
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:
1407807118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3025 HAMILTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51104-2407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-255-8055
Provider Business Mailing Address Fax Number:
712-255-4784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3025 HAMILTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51104-2407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-255-8055
Provider Business Practice Location Address Fax Number:
712-255-4784
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BETTIGA
Authorized Official First Name:
MICAEL
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: 332B00000X ; 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: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 514 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8531562 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9164712 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0495028 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1613531 . This is a "NCPDP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 41098505408 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8531560 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025413500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0208470 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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