Healthcare Provider Details

I. General information

NPI: 1174740682
Provider Name (Legal Business Name): RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 02/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W WAYNE ST
LAGRANGE IN
46761-1850
US

IV. Provider business mailing address

201 W WAYNE ST PO BOX 150
LAGRANGE IN
46761-1850
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-3421
  • Fax: 260-463-7347
Mailing address:
  • Phone: 260-463-3421
  • Fax: 260-463-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number18002670A/B
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002670A/B
License Number StateIN

VIII. Authorized Official

Name: DR. RICKY LEE WEIDOW
Title or Position: PRESIDENT
Credential: O.D.
Phone: 260-463-3421