Provider Demographics
NPI:1366608440
Name:SHOPKO STORES OPERATING CO LLC
Entity type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:3271 MARKETPLACE DR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-7908
Mailing Address - Country:US
Mailing Address - Phone:712-366-0706
Mailing Address - Fax:712-366-9020
Practice Address - Street 1:3271 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-7908
Practice Address - Country:US
Practice Address - Phone:712-366-0706
Practice Address - Fax:712-366-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1366608440OtherWELLMARK BCBS IA
51451OtherAVESIS
A00793OtherEYEMED
62213OtherSPECTERA
135093OtherVIP
51451OtherAVESIS
IAI17682003Medicare PIN
A00793OtherEYEMED