Healthcare Provider Details

I. General information

NPI: 1063078442
Provider Name (Legal Business Name): SHOPTIKAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2019
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W IRONWOOD DR STE B&C
COEUR D ALENE ID
83814-1403
US

IV. Provider business mailing address

PO BOX 19060
GREEN BAY WI
54307-9060
US

V. Phone/Fax

Practice location:
  • Phone: 208-765-8078
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JAMES EISEN
Title or Position: EVP & CFO
Credential:
Phone: 920-429-7549