Healthcare Provider Details

I. General information

NPI: 1336297308
Provider Name (Legal Business Name): LOUISVILLE OPTOMETRIC CENTERS, III PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5023 MUD LANE SUITE 110
LOUISVILLE KY
40229-2870
US

IV. Provider business mailing address

4000 POPLAR LEVEL RD
LOUISVILLE KY
40213-1524
US

V. Phone/Fax

Practice location:
  • Phone: 502-968-2015
  • Fax: 502-964-1915
Mailing address:
  • Phone: 502-459-2020
  • Fax: 502-456-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1670DT
License Number StateKY

VIII. Authorized Official

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