Healthcare Provider Details

I. General information

NPI: 1649745191
Provider Name (Legal Business Name): LOUISVILLE OPTOMETRIC CENTER III, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 HUBBARDS LANE SUITE 300
LOUISVILLE KY
40207
US

IV. Provider business mailing address

4000 POPLAR LEVEL RD
LOUISVILLE KY
40213-1524
US

V. Phone/Fax

Practice location:
  • Phone: 502-454-9122
  • Fax: 502-895-3602
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 Number
License Number State

VIII. Authorized Official

Name: MARY MCCLOSKEY
Title or Position: CREDENTIALING
Credential:
Phone: 502-813-8923