Provider Demographics
NPI:1265484265
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 012
Other - Org Type:Doing Business As
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 1:1100 E RIVERVIEW EXPY
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-5483
Mailing Address - Country:US
Mailing Address - Phone:715-423-1340
Mailing Address - Fax:
Practice Address - Street 1:1100 E RIVERVIEW EXPY
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5483
Practice Address - Country:US
Practice Address - Phone:715-423-1340
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
014012OtherVIP
13864OtherMEDICARE
35595OtherAVESIS
410985054-4012OtherNVA
42587OtherDAVIS
WI38409000Medicaid
CP2230-93OtherEYEMED
87832OtherMEDICARE
WI5695760005Medicare NSC
014012OtherVIP
13864OtherMEDICARE