Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Eyecare Center # 4216
Organization subpart
No
Provider details
NPI number
Authorized official
DILIP SEDANI (VP)
(920) 429-7688
Entity
Organization
Contact information
Practice address
10996 N PORT WASHINGTON RD, MEQUON, WI 53092
(262) 240-9870
Mailing address
700 PILGRIM WAY, GREEN BAY, WI 54304-5263
(920) 429-2211
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1427547082
—
WI
Enumeration date
05/08/2018
Last updated
07/25/2018
About Stedi
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