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General NPI Number Information
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NPI Number | 1174740682
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Entity Type | Organization
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Legal Business Name | RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 02/27/2010
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Provider Practice Location Address
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Address Line | 201 W WAYNE ST
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City | LAGRANGE
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State | IN
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Zip | 46761-1850
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Country | US
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Telephone | 260-463-3421
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Fax | 260-463-7347
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Provider Business Mailing Address
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Address Line | 201 W WAYNE ST PO BOX 150
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City | LAGRANGE
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State | IN
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Zip | 46761-1850
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Country | US
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Telephone | 260-463-3421
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Fax | 260-463-7347
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICKY LEE WEIDOW
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Credential | O.D.
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Telephone | 260-463-3421
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 18002670A/B
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18002670A/B
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License Number State | IN
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