Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 029
Organization subpart
No
Provider details
NPI number
Authorized official
DILIP SEDANI (E)
(920) 429-7688
Entity
Organization
Contact information
Practice address
7401 MINERAL POINT RD, MADISON, WI 53717
(608) 833-5700
Mailing address
7401 MINERAL POINT RD, MADISON, WI 53717-1703
(608) 833-5700
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000087848
MEDICARE
—
01
—
014029
VIIP
—
01
—
17647
MEDICARE
—
01
—
35571
AVESIS
—
05
—
38412900
—
WI
01
—
410985054-4029
NVA
—
01
—
42622
DAVIS
—
01
—
CP2230-76
EYEMED
—
Enumeration date
05/16/2006
Last updated
06/08/2018
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