Provider Demographics
NPI:1992095012
Name:LOUISVILLE OPTOMETRIC CENTERS, III PSC
Entity type:Organization
Organization Name:LOUISVILLE OPTOMETRIC CENTERS, III PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROD
Authorized Official - Middle Name:L
Authorized Official - Last Name:RALLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:502-459-2020
Mailing Address - Street 1:279 N GARDNER ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-1322
Mailing Address - Country:US
Mailing Address - Phone:812-752-5106
Mailing Address - Fax:812-752-5132
Practice Address - Street 1:279 N GARDNER ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-1322
Practice Address - Country:US
Practice Address - Phone:812-752-5106
Practice Address - Fax:812-752-5132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200502740CMedicaid
IN200502740CMedicaid