Healthcare Provider Details

I. General information

NPI: 1164103669
Provider Name (Legal Business Name): LOUISVILLE OPTOMETRIC CENTERS III, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2618 RING RD STE 108
ELIZABETHTOWN KY
42701-9118
US

IV. Provider business mailing address

4000 POPLAR LEVEL RD
LOUISVILLE KY
40213-1524
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-1128
  • Fax: 270-854-1641
Mailing address:
  • Phone: 502-459-3136
  • Fax: 502-456-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

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