Healthcare Provider Details

I. General information

NPI: 1255974481
Provider Name (Legal Business Name): LOUISVILLE OPTOMETRIC CENTERS III, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 E 10TH ST
JEFFERSONVILLE IN
47130-9315
US

IV. Provider business mailing address

4000 POPLAR LEVEL RD
LOUISVILLE KY
40213-1524
US

V. Phone/Fax

Practice location:
  • Phone: 812-590-6810
  • Fax: 812-590-6762
Mailing address:
  • Phone: 502-459-2020
  • Fax: 502-456-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROD RALLO
Title or Position: OWNER
Credential: OD
Phone: 502-459-2020