Provider Demographics
NPI:1205906930
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 AND OPTOMETRIST
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 1:109 S WALTERS AVE
Mailing Address - Street 2:
Mailing Address - City:HODGENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42748-1533
Mailing Address - Country:US
Mailing Address - Phone:270-358-8141
Mailing Address - Fax:270-358-4556
Practice Address - Street 1:109 S WALTERS AVE
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-1533
Practice Address - Country:US
Practice Address - Phone:270-358-8141
Practice Address - Fax:270-358-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5419240003332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5419240003Medicare NSC