1467522029 NPI number — LOUISVILLE OPTOMETRIC CENTERS, III PSC

Table of content: (NPI 1467522029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467522029 NPI number — LOUISVILLE OPTOMETRIC CENTERS, III PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUISVILLE OPTOMETRIC CENTERS, III PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467522029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5023 MUD LANE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40229-2870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-968-2015
Provider Business Mailing Address Fax Number:
502-964-1915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5023 MUD LANE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40229-2870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-968-2015
Provider Business Practice Location Address Fax Number:
502-964-1915
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RALLO
Authorized Official First Name:
ROD
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER AND OPTOMETRIST
Authorized Official Telephone Number:
502-459-2020

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  5419240011 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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