Shopko Stores Operating Company
Organization Active NPI Optometrist · Green Bay, WI
NPI 1962452052 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1962452052
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Optometrist 152W00000X
- License
- 1643-035 (WI)
- Legal business name
- SHOPKO STORES OPERATING COMPANY
- Practice address
- 2430 E Mason St
Green Bay, WI 54302-3759 - Phone
- (920) 468-4642
- Fax
- (920) 468-3490
- NPI assigned
- May 11, 2006
- Organization subpart
- No
Authorized official
- Name
- Mr. James L Schmonsky III, OD
- Title
- Optometrist
- Phone
- (920) 468-4642
Corporate family (same tax ID) 15
National Provider Directory
- Tax ID family
- Shopko Stores Operat Co LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | 1643-035 | WI | Yes |
Addresses
Primary practice location
2430 E Mason St
Green Bay, WI 54302-3759
Mailing address
2430 E Mason St
Green Bay, WI 54302-3759
Phone (920) 468-4642
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 38403100 | Medicaid | WI |
Other providers in Green Bay, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.