Provider Demographics
NPI:1083741326
Name:LOUISVILLE OPTOMETRIC CENTER, III, PSC
Entity Type:Organization
Organization Name:LOUISVILLE OPTOMETRIC CENTER, III, PSC
Other - Org Name:VISIONFIRST
Other - Org Type:Doing Business As
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 1:4000 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1524
Mailing Address - Country:US
Mailing Address - Phone:502-459-2020
Mailing Address - Fax:502-456-9121
Practice Address - Street 1:815 MAIN ST.
Practice Address - Street 2:
Practice Address - City:MUNFORDVILLE
Practice Address - State:KY
Practice Address - Zip Code:42765
Practice Address - Country:US
Practice Address - Phone:270-524-5444
Practice Address - Fax:270-524-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100010580Medicaid