Provider Demographics
NPI:1346292745
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 029
Other - Org Type:Doing Business As
Authorized Official - Title/Position:E
Authorized Official - Prefix:
Authorized Official - First Name:DILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:SEDANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-429-7688
Mailing Address - Street 1:7401 MINERAL POINT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1703
Mailing Address - Country:US
Mailing Address - Phone:608-833-5700
Mailing Address - Fax:
Practice Address - Street 1:7401 MINERAL POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717
Practice Address - Country:US
Practice Address - Phone:608-833-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38412900Medicaid
42622OtherDAVIS
000087848OtherMEDICARE
35571OtherAVESIS
CP2230-76OtherEYEMED
17647OtherMEDICARE
410985054-4029OtherNVA
014029OtherVIIP
014029OtherVIIP
0154160134Medicare ID - Type Unspecified