1629021480 NPI number — SHOPKO STORES OPERATING CO. LLC

Table of content: (NPI 1629021480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629021480 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:
1629021480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4810 AVENUE O
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MADISON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52627-9677
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-372-8633
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4810 AVENUE O
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MADISON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52627-9677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-372-8633
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: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: I8499 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 014142 . This is a "VIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0252080 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CP2521-2 . This is a "EYEMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 17709 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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