Provider Demographics
NPI:1528010642
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 060
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 1:2610 BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2075
Mailing Address - Country:US
Mailing Address - Phone:507-373-2269
Mailing Address - Fax:
Practice Address - Street 1:2610 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2075
Practice Address - Country:US
Practice Address - Phone:507-373-2269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
410985054-4060OtherNATIONAL VISION ADMIN.
014060OtherVIP
36059OtherMN HEALTH PARTNERS
21000715OtherMN MA MEDICA CHOICE CARE
30329SHOtherMN BLUE PLUS CARE
35466OtherAVESIS
03092036206OtherMN MA PRIMEWEST HEALTH
30328SHOtherMN MA FIRST PLAN OF MN
17831OtherMEDICARE
42496OtherDAVIS
CP2230-17OtherEYEMED
30329SHOtherMN BLUE PLUS CARE
35466OtherAVESIS
MN5695760094Medicare NSC
DF0849Medicare PIN