Shopko Stores Operating Co LLC

Primary specialty

Eyewear SupplierTaxonomy code 332H00000X

Legal business name

SHOPKO STORES OPERATING CO LLC

Practice address

60 NE Bend River Mall Dr
Bend, OR 97701-7528

Phone

(541) 385-6079

NPI assigned

May 12, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Michael J Bettiga, RPH

Title

Sr. Vice President Health Services

Phone

(920) 429-4297

Specialties & licenses 1

Addresses

Other identifiers 8

Other names 1

• ShopKo Optical 093 Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147392000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1205884800000",
    "number": "1023069499",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "60 NE BEND RIVER MALL DR",
            "city": "BEND",
            "state": "OR",
            "postal_code": "977017528",
            "telephone_number": "541-385-6079"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "60 NE BEND RIVER MALL DR",
            "city": "BEND",
            "state": "OR",
            "postal_code": "977017528",
            "telephone_number": "541-385-6079"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-12",
        "last_updated": "2008-03-19",
        "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_name_prefix": "Mr.",
        "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": "MEDICARECOMPLETE",
            "identifier": "17679",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AVESIS",
            "identifier": "35508",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "022688",
            "state": "OR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VIP",
            "identifier": "014093",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OR MEDICARE-NORIDIAN",
            "identifier": "112254",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EYEMED",
            "identifier": "CP2230-33",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DAVIS VISION",
            "identifier": "42573",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "005251",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Optical 093",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Keiji Jay Shiyomura, OD
• Jena Shlegeris
• Jessica K Shoemaker
• Luke Shoemaker
• Steven Louis Shope, BS
• Shopko Stores Operating Co LLC
• Adam Jeffrey Short, PA-C
• Dominika Rose Short
• Richard H Shortall, PT
• Bradley Show, LPC

• Eyewear Supplier in Bend, OR
• Providers in Bend, OR by specialty
• Eyewear Supplier in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 19, 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.

Verify at the official NPI Registry.