SHOPKO OPTICAL 093
Complete NPI Record 1023069499
Eyewear Supplier in Bend, OR

Active since May 12, 2006

60 NE BEND RIVER MALL DR, BEND, OR 97701(541) 385-6079 Get Directions

NPPES record last updated: March 19, 2008. Verified against the NPPES registry weekly; last sync: July 19, 2026.

Complete NPI Dataset

This page contains the complete raw NPPES record for Shopko Optical 093 (NPI 1023069499), an eyewear supplier organization in Bend, OR. All 54 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.

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NPI: 1023069499: The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 2: Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: Not available: The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
Provider Organization Name Legal Business Name: SHOPKO STORES OPERATING CO LLC: The name of the organization provider. If the provider is an organization, this is the legal business name.
Provider Other Organization Name: SHOPKO OPTICAL 093: Other name by which the organization provider is or has been known.
Provider Other Organization Name Type Code: 3: Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
Provider First Line Business Mailing Address: 60 NE BEND RIVER MALL DR: The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
Provider Business Mailing Address City Name: BEND: The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: OR: The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
Provider Business Mailing Address Postal Code: 977017528: The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
Provider Business Mailing Address Country Code If outside U S : US: The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
Provider Business Mailing Address Telephone Number: 5413856079: The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
Provider First Line Business Practice Location Address: 60 NE BEND RIVER MALL DR: The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: BEND: The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: OR: The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 977017528: The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US: The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 5413856079: The telephone number associated with the location address of the provider being identified.
Provider Enumeration Date: 5/12/2006: The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 3/19/2008: The date that a record was last updated or changed.
Authorized Official Last Name: BETTIGA: The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: MICHAEL: The first name of the authorized official.
Authorized Official Middle Name: J: The middle name of the authorized official.
Authorized Official Title or Position: SR. VICE PRESIDENT HEALTH SERVICES: The title or position of the authorized official.
Authorized Official Telephone Number: 9204294297: The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 332H00000X: This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 1: Y: This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
Other Provider Identifier 1: 014093: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 1: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier Issuer 1: VIP: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 2: 42573: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 2: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier Issuer 2: DAVIS VISION: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 3: 112254: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 3: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier Issuer 3: OR MEDICARE-NORIDIAN: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 4: 17679: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 4: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier Issuer 4: MEDICARECOMPLETE: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 5: 35508: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 5: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier Issuer 5: AVESIS: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 6: CP2230-33: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 6: 01: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier Issuer 6: EYEMED: The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
Other Provider Identifier 7: 005251: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 7: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 7: OR: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Other Provider Identifier 8: 022688: An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
Other Provider Identifier Type Code 8: 05: A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
Other Provider Identifier State 8: OR: The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
Is Organization Subpart: N: Indicates whether the provider is a subpart of a larger organization. This is a single-character code: "Y" means the entity is an organizational subpart, while "N" means it is not. Subparts typically include hospital departments, clinics, or other distinct units that fall under a parent organization.
Authorized Official Name Prefix Text: MR.: The prefix used in the name of the authorized official associated with the provider's NPI record. Examples include Mr., Ms., Mrs., Dr., or other common professional or personal prefixes.
Authorized Official Credential Text: RPH: The professional credential(s) of the authorized official listed on the provider's NPI record. Examples include MD (Doctor of Medicine), DO (Doctor of Osteopathy), RN (Registered Nurse), DDS (Doctor of Dental Surgery), PhD, or other recognized designations that reflect the official's qualifications.

Other Provider Identifiers 12

Legacy and payer-issued identifiers reported to the NPPES registry for this provider.

17679 Other

1/12

Issuer: Medicarecomplete
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

42573 Other

2/12

Issuer: Davis Vision
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

022688 Medicaid

3/12

State: OR
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

5695760101 Medicare NSC

4/12

State: OR
Medicare NSC: Used in the "Other Provider Identifier" field when listing non-NPI legacy provider numbers associated with a health care practitioner or organization in NPPES.

CP2230-33 Other

5/12

Issuer: Eyemed
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

014093 Other

6/12

Issuer: Vip
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

005251 Medicaid

7/12

State: OR
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.

0154160025 Medicare ID-Type Unspecified

8/12

Medicare ID (Type Unspecified): A Medicare-issued provider identifier whose specific subtype or program context has not been designated.

R134768 Medicare PIN

9/12

State: OR
Medicare PIN: Used in legacy data fields alongside a healthcare provider's National Provider Identifier (NPI) to designate legacy Medicare provider numbers.

DF1182 Medicare PIN

10/12

Medicare PIN: Used in legacy data fields alongside a healthcare provider's National Provider Identifier (NPI) to designate legacy Medicare provider numbers.

35508 Other

11/12

Issuer: Avesis
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

112254 Other

12/12

Issuer: Or Medicare-noridian
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.

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