Provider Demographics
NPI:1174740682
Name:RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.
Entity type:Organization
Organization Name:RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WEIDOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-463-3421
Mailing Address - Street 1:201 W WAYNE ST
Mailing Address - Street 2:PO BOX 150
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-1850
Mailing Address - Country:US
Mailing Address - Phone:260-463-3421
Mailing Address - Fax:260-463-7347
Practice Address - Street 1:201 W WAYNE ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1850
Practice Address - Country:US
Practice Address - Phone:260-463-3421
Practice Address - Fax:260-463-7347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002670A/B332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2605932505OtherVISION SERVICE PLAN TOPEKA
IN5742334109OtherVISION SERVICE PLAN SOUTH BEND
IN200097680DMedicaid
IN2604633421OtherVISION SERVICE PLAN LAGRANGE
IN000000257711OtherANTHEM BC/BS LAGRANGE
IN000000257712OtherANTHEM BC/BS TOPEKA
IN000000635212OtherANTHEM NWIELC KNOX
IN200097680EMedicaid
IN1639177793OtherRICKY WEIDOW NPI
IN200097680CMedicaid
IN410043916Medicare PIN
IN000000257712OtherANTHEM BC/BS TOPEKA
IN200097680CMedicaid
IN461830Medicare PIN
IN4002320001Medicare NSC
IN4002320002Medicare NSC
IN000000635212OtherANTHEM NWIELC KNOX
IN000000257711OtherANTHEM BC/BS LAGRANGE
IN200097680DMedicaid
IN169220Medicare PIN
IN461830AMedicare PIN
IN180230Medicare PIN