=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861540833
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUISVILLE OPTOMETRIC CENTERS, III PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 03/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12911 SHELBYVILLE RD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40243-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-254-1100
-----------------------------------------------------
Fax | 502-254-7634
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 POPLAR LEVEL RD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40213-1524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-459-2020
-----------------------------------------------------
Fax | 502-456-9121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROD L. RALLO
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 502-459-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1482DT
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------