Provider Demographics
NPI:1366495954
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 036
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 1:3708 HWY 63 N
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-3902
Mailing Address - Country:US
Mailing Address - Phone:507-281-0657
Mailing Address - Fax:
Practice Address - Street 1:3708 HWY 63 N
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-3902
Practice Address - Country:US
Practice Address - Phone:507-281-0657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
20019120529OtherMN MA PRIMEWEST HEALTH
64031SHOtherMN MA FIRST PLAN OF MN
213121-16OtherEYEMED
42619OtherDAVIS
35472OtherAVESIS
411740865-4036OtherNATIONAL VISION ADMIN.
17826OtherMEDICARE
36056OtherMN HEALTH PARTNERS
20019120529OtherMN MA PRIMEWEST HEALTH
411740865-4036OtherNATIONAL VISION ADMIN.
35472OtherAVESIS
213121-16OtherEYEMED