Active NPI
Shopko Stores Operating Co. LLC
- Eyewear Supplier
- Fond Du Lac, WI
National Provider Identifier
1013960723
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Eyewear Supplier
- Legal business name
- SHOPKO STORES OPERATING CO. LLC
- Practice address
- 616 W Johnson St
Fond Du Lac, WI 54935-3134 - Phone
- (920) 921-8290
- NPI assigned
- May 17, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Michael J Bettiga, RPH
- Title
- Sr. Vice President Health Services
- Phone
- (920) 429-4297
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Eyewear Supplier | 332H00000X | Primary |
Addresses
Primary practice location
616 W Johnson St
Fond Du Lac, WI 54935-3134
Mailing address
616 W Johnson St
Fond Du Lac, WI 54935-3134
Phone (920) 921-8290
Other identifiers 7
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 014050 | Other | VIP | |
| 410985054-4050 | Other | NVA | |
| 17654 | Other | MEDICARE | |
| 35560 | Other | AVESIS | |
| CP2230-3 | Other | EYEMED | |
| 38426900 | Medicaid | WI | |
| 42597 | Other | DAVIS |
Other names 1
- ShopKo Optical 050
National Provider Directory
National Provider DirectoryNPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1147824000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1202688000000",
"number": "1013960723",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "616 W JOHNSON ST",
"city": "FOND DU LAC",
"state": "WI",
"postal_code": "549353134",
"telephone_number": "920-921-8290"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "616 W JOHNSON ST",
"city": "FOND DU LAC",
"state": "WI",
"postal_code": "549353134",
"telephone_number": "920-921-8290"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "SHOPKO STORES OPERATING CO. LLC",
"organizational_subpart": "NO",
"enumeration_date": "2006-05-17",
"last_updated": "2008-02-11",
"status": "A",
"authorized_official_last_name": "BETTIGA",
"authorized_official_first_name": "MICHAEL",
"authorized_official_middle_name": "J",
"authorized_official_title_or_position": "SR. VICE PRESIDENT HEALTH SERVICES",
"authorized_official_telephone_number": "920-429-4297",
"authorized_official_credential": "RPH"
},
"taxonomies": [
{
"code": "332H00000X",
"taxonomy_group": "",
"desc": "Eyewear Supplier",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "VIP",
"identifier": "014050",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NVA",
"identifier": "410985054-4050",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE",
"identifier": "17654",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AVESIS",
"identifier": "35560",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "EYEMED",
"identifier": "CP2230-3",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "38426900",
"state": "WI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DAVIS",
"identifier": "42597",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "ShopKo Optical 050",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Fond Du Lac, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.