Healthcare Provider Details

I. General information

NPI: 1285704866
Provider Name (Legal Business Name): LOUISVILLE OPTOMETRIC CENTERS, III PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MAIN ST
SALEM IN
47167-1040
US

IV. Provider business mailing address

600 S MAIN ST
SALEM IN
47167-1040
US

V. Phone/Fax

Practice location:
  • Phone: 812-883-2700
  • Fax: 812-883-2752
Mailing address:
  • Phone: 812-883-2700
  • Fax: 812-883-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number5419240006
License Number StateIN

VIII. Authorized Official

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