NPIMap

Organization Active NPI

Shopko Stores Operating,Co.,LLC

  • Optometrist
  • Oregon, WI
National Provider Identifier
1265483168
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
1772 Issued in WI
Legal business name
SHOPKO STORES OPERATING,CO.,LLC
Practice address
6218 Trail Ridge CT
Oregon, WI 53575-2534
Phone
(608) 222-9420
Fax
(608) 222-0578
NPI assigned
May 15, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Dr. Richard Dewey Olson, O.D.NPI 1053355610
Title
Optomotrist
Phone
(608) 222-9420

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X 1772 WI Primary

Addresses

Primary practice location

6218 Trail Ridge CT
Oregon, WI 53575-2534

Mailing address

6218 Trail Ridge CT
Oregon, WI 53575-2534
Phone (608) 222-9420

Other identifiers 1

IdentifierTypeStateIssuer
38416300MedicaidWI

National Provider Directory

National Provider Directory
Tax ID family
Shopko2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1147651200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1265483168",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6218 TRAIL RIDGE CT",
            "city": "OREGON",
            "state": "WI",
            "postal_code": "535752534",
            "telephone_number": "608-222-9420",
            "fax_number": "608-222-0578"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6218 TRAIL RIDGE CT",
            "city": "OREGON",
            "state": "WI",
            "postal_code": "535752534",
            "telephone_number": "608-222-9420",
            "fax_number": "608-222-0578"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO STORES OPERATING,CO.,LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-15",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "OLSON",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "DEWEY",
        "authorized_official_title_or_position": "OPTOMOTRIST",
        "authorized_official_telephone_number": "608-222-9420",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "WI",
            "license": "1772",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38416300",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Oregon, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.