MEDICARE: LOUISVILLE OPTOMETRIC CENTERS, III PSC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	200502740A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568537728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISVILLE OPTOMETRIC CENTERS, III PSC

Provider Business Mailing Address
First Line	:	600 S MAIN ST
Second Line	:
City	:	SALEM
State	:	IN
Zip	:	47167-1040
Country	:	US
Telephone Number	:	812-883-2700
Fax Number	:	812-883-2752

Provider Business Practice Location Address
First Line	:	600 S MAIN ST
Second Line	:
City	:	SALEM
State	:	IN
Zip	:	47167-1040
Country	:	US
Telephone Number	:	812-883-2700
Fax Number	:	812-883-2752

Authorized Official
Title or Position	:	OWNER AND OPTOMETRIST
Name	:	DR. ROD L. RALLO
Credential	:	O.D.
Telephone Number	:	502-459-2020

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	02/19/2014

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