MEDICARE: SHOPKO STORES OPERATING CO. LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	152W00000X	Optometrist
2	156FX1800X	Optician
3	332H00000X	Eyewear Supplier

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	17933	OTHER		MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CP2230-50	OTHER		EYEMED
2	35534	OTHER		AVESIS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	410985054-4110	OTHER		NATIONAL VISION ADMIN
6	014110	OTHER		VIP
7	42512	OTHER		DAVIS
8	UT03960	OTHER	UT	NORIDIAN SUBMITTER ID

General Provider Information

NPI Number	:	1568415339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPKO STORES OPERATING CO. LLC

Provider Business Mailing Address
First Line	:	2290 S 1300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2831
Country	:	US
Telephone Number	:	801-467-8989
Fax Number	:

Provider Business Practice Location Address
First Line	:	2290 S 1300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2831
Country	:	US
Telephone Number	:	801-467-8989
Fax Number	:

Authorized Official
Title or Position	:	SR. VICE PRESIDENT HEALTH SERVICES
Name	:	MICHAEL J BETTIGA
Credential	:	RPH
Telephone Number	:	920-429-4297

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	07/10/2008

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