Provider Demographics
NPI:1649745191
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:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLOSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-813-8923
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 1:285 HUBBARDS LANE
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-454-9122
Practice Address - Fax:502-895-3602
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOUISVILLE OPTOMETRIC CENTERS III PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-11
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100010580Medicaid