Organization
SHOPKO STORES OPERATING CO. LLC
Active
Other names
ShopKo Optical 133
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL J BETTIGA RPH (SR. VICE PRESIDENT HEALTH SERVICES)
(920) 429-4297
Entity
Organization
Contact information
Practice address
1400 BIG THUNDER BLVD, BELVIDERE, IL 61008-1726
(815) 547-3456
Mailing address
1400 BIG THUNDER BLVD, BELVIDERE, IL 61008-1726
(815) 547-3456
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
014133
VIP
—
01
—
17685
MEDICARE
—
01
—
35452
AVESIS
—
01
—
42552
DAVIS
—
01
—
5232016
BCBS IL
IL
01
—
CP2230-12
EYEMED
—
Enumeration date
05/17/2006
Last updated
06/04/2008
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