NPIMap

Organization Active NPI

Shopko Optical Manufacturing LLC

  • Eyewear Supplier
  • De Pere, WI
National Provider Identifier
1821243650
Registry record updated Feb 24, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Eyewear SupplierTaxonomy code 332H00000X
Legal business name
SHOPKO OPTICAL MANUFACTURING LLC
Practice address
1450 W Main Ave
De Pere, WI 54115-9369
Phone
(920) 429-7253
NPI assigned
Nov 20, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 24, 2009

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

Authorized official

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Eyewear Supplier 332H00000X Primary

Addresses

Primary practice location

1450 W Main Ave
De Pere, WI 54115-9369

Mailing address

1450 W Main Ave
De Pere, WI 54115-9369
Phone (920) 429-7179

Other identifiers 1

IdentifierTypeStateIssuer
38456800MedicaidWI

National Provider Directory

National Provider Directory

Locations

1450 W Main Ave
De Pere, WI 54115
Phone (920) 429-7253

NPI Registry JSON

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

{
    "created_epoch": "1227139200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1235433600000",
    "number": "1821243650",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1450 W MAIN AVE",
            "city": "DE PERE",
            "state": "WI",
            "postal_code": "541159369",
            "telephone_number": "920-429-7179"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1450 W MAIN AVE",
            "city": "DE PERE",
            "state": "WI",
            "postal_code": "541159369",
            "telephone_number": "920-429-7253"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHOPKO OPTICAL MANUFACTURING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-11-20",
        "last_updated": "2009-02-24",
        "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_name_prefix": "Mr.",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38456800",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in De Pere, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 24, 2009; 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.