Renaissance Ocular Disease and Trauma Foundation, Inc.

Primary specialty

OptometristTaxonomy code 152W00000X

License

18002670A/B Issued in IN

Legal business name

RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.

Practice address

201 W Wayne St
Lagrange, IN 46761-1850

Phone

(260) 463-3421

Fax

(260) 463-7347

NPI assigned

Apr 19, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Ricky Lee Weidow, O.D.

Title

President

Phone

(260) 463-3421

Specialties & licenses 2

Addresses

Other identifiers 10

Other names 1

• Evergreen Eye Clinic Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176940800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1267228800000",
    "number": "1174740682",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "201 W WAYNE ST",
            "address_2": "PO BOX 150",
            "city": "LAGRANGE",
            "state": "IN",
            "postal_code": "467611850",
            "telephone_number": "260-463-3421",
            "fax_number": "260-463-7347"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 W WAYNE ST",
            "city": "LAGRANGE",
            "state": "IN",
            "postal_code": "467611850",
            "telephone_number": "260-463-3421",
            "fax_number": "260-463-7347"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-19",
        "last_updated": "2010-02-27",
        "status": "A",
        "authorized_official_last_name": "WEIDOW",
        "authorized_official_first_name": "RICKY",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "260-463-3421",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "IN",
            "license": "18002670A/B",
            "primary": true
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "IN",
            "license": "18002670A/B",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VISION SERVICE PLAN TOPEKA",
            "identifier": "2605932505",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VISION SERVICE PLAN SOUTH BEND",
            "identifier": "5742334109",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200097680D",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VISION SERVICE PLAN LAGRANGE",
            "identifier": "2604633421",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM BC/BS LAGRANGE",
            "identifier": "000000257711",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM BC/BS TOPEKA",
            "identifier": "000000257712",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM NWIELC KNOX",
            "identifier": "000000635212",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200097680E",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RICKY WEIDOW NPI",
            "identifier": "1639177793",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200097680C",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Evergreen Eye Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Optometrist in Lagrange, IN
• Providers in Lagrange, IN by specialty
• Optometrist in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 27, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.