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General NPI Number Information
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NPI Number | 1619929015
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Entity Type | Organization
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Legal Business Name | SHOPKO STORES OPERATING CO. LLC
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Dates
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Enumeration Date | 05/16/2006
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Last Update Date | 09/28/2007
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Provider Practice Location Address
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Address Line | 105 N MAIN ST
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City | EAST PEORIA
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State | IL
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Zip | 61611-2543
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Country | US
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Telephone | 309-694-6470
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Fax |
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Provider Business Mailing Address
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Address Line | 105 N MAIN ST
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City | EAST PEORIA
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State | IL
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Zip | 61611-2543
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Country | US
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Telephone | 309-694-6470
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Fax |
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Authorized Official
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Title or Position | SR. VICE PRESIDENT HEALTH SERVICES
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Name | MICHAEL J BETTIGA
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Credential | RPH
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Telephone | 920-429-4297
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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