Provider Demographics
NPI:1013969336
Name:SHOPKO STORES OPERATING CO. LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO. LLC
Other - Org Name:SHOPKO OPTICAL 016
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
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 1:2530 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1390
Mailing Address - Country:US
Mailing Address - Phone:906-786-2295
Mailing Address - Fax:
Practice Address - Street 1:2530 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1390
Practice Address - Country:US
Practice Address - Phone:906-786-2295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
014016OtherVIP
42600OtherDAVIS
0P06330OtherMEDICARE
17875OtherMEDICARE
213121-9OtherEYEMED
35462OtherAVESIS
411740865-4016OtherNVA
1111590049Medicare ID - Type Unspecified
411740865-4016OtherNVA
DF0754Medicare PIN
17875OtherMEDICARE