NPIMap

Organization Active NPI

Shopko Stores Operating Co LLC

Doing business as ShopKo Optical 504

  • Eyewear Supplier
  • Appleton, WI
National Provider Identifier
1114100518
Registry record updated Jul 17, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Eyewear SupplierTaxonomy code 332H00000X
Legal business name
SHOPKO STORES OPERATING CO LLC
Doing business as
ShopKo Optical 504
Practice address
W3208 Van Roy Rd
Appleton, WI 54915
Phone
(920) 111-1111
NPI assigned
Dec 10, 2007
Last updated
Jul 17, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 17, 2008

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

Authorized official

Name
Michael Bettiga, RPH
Title
Sr. Vice President Health Services
Phone
(920) 429-4297

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Eyewear Supplier 332H00000X Primary

Addresses

Primary practice location

W3208 Van Roy Rd
Appleton, WI 54915

Mailing address

W3208 Van Roy Rd
Appleton, WI 54915

Other identifiers 5

IdentifierTypeStateIssuer
1114100518OtherANTHEM BCBS WI
38461200MedicaidWI
59715OtherDAVIS
60677OtherSPECTERA
300133OtherEYEMED

Other names 1

  • ShopKo Optical 504 Doing business as

National Provider Directory

National Provider Directory

Locations

W3208 Van Roy Rd
Appleton, WI 54915
Phone (866) 455-8111

NPI Registry JSON

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

{
    "created_epoch": "1197244800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1216252800000",
    "number": "1114100518",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "W3208 VAN ROY RD",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "54915"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "W3208 VAN ROY RD",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "54915",
            "telephone_number": "920-111-1111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING CO LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-10",
        "last_updated": "2008-07-17",
        "status": "A",
        "authorized_official_last_name": "BETTIGA",
        "authorized_official_first_name": "MICHAEL",
        "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": "ANTHEM BCBS WI",
            "identifier": "1114100518",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38461200",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DAVIS",
            "identifier": "59715",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SPECTERA",
            "identifier": "60677",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EYEMED",
            "identifier": "300133",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ShopKo Optical 504",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Appleton, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 17, 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.