Provider Demographics
NPI:1295788834
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:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:2200 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-3631
Mailing Address - Country:US
Mailing Address - Phone:715-362-4800
Mailing Address - Fax:
Practice Address - Street 1:2200 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3631
Practice Address - Country:US
Practice Address - Phone:715-362-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP2230-87OtherEYEMED
42569OtherDAVIS
47535OtherMEDICARE
410985054-4170OtherNVA
014170OtherVIP
35585OtherAVESIS
WI38454100Medicaid
17665OtherMEDICARE
WI5695760019Medicare NSC
014170OtherVIP
42569OtherDAVIS