Provider Demographics
NPI:1558314328
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 080
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
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 1:2201 ZEIER RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-7415
Mailing Address - Country:US
Mailing Address - Phone:608-246-2161
Mailing Address - Fax:
Practice Address - Street 1:2201 ZEIER RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704
Practice Address - Country:US
Practice Address - Phone:608-246-2161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2018-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP2230-78OtherEYEMED
42536OtherDAVIS
000087921OtherMEDICARE
014080OtherVIP
410985054-4080OtherNVA
WI38707300Medicaid
17657OtherMEDICARE
35574OtherAVESIS
410985054-4080OtherNVA
42536OtherDAVIS