Healthcare Provider Details

I. General information

NPI: 1689415176
Provider Name (Legal Business Name): LOUISVILLE OPTOMETRIC CENTER III, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11809 STANDIFORD PLAZA DR STE 1
LOUISVILLE KY
40229-5907
US

IV. Provider business mailing address

11809 STANDIFORD PLAZA DR STE 1
LOUISVILLE KY
40229-5907
US

V. Phone/Fax

Practice location:
  • Phone: 502-964-9400
  • Fax:
Mailing address:
  • Phone: 502-964-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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