Healthcare Provider Details

I. General information

NPI: 1881079762
Provider Name (Legal Business Name): LOUISVILLE OPTOMETRIC CENTERS, III PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6812 DIXIE HWY
LOUISVILLE KY
40258-3914
US

IV. Provider business mailing address

6812 DIXIE HWY
LOUISVILLE KY
40258-3914
US

V. Phone/Fax

Practice location:
  • Phone: 502-933-7986
  • Fax: 502-933-2652
Mailing address:
  • Phone: 502-933-7986
  • Fax: 502-933-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number936DT
License Number StateKY

VIII. Authorized Official

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