Organization
RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.
Active
Other names
Evergreen Eye Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RICKY LEE WEIDOW O.D. (PRESIDENT)
(260) 463-3421
Entity
Organization
Contact information
Practice address
201 W WAYNE ST, LAGRANGE, IN 46761-1850
(260) 463-3421
(260) 463-7347
Mailing address
201 W WAYNE ST, PO BOX 150, LAGRANGE, IN 46761-1850
(260) 463-3421
(260) 463-7347
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
18002670A/B
IN
332H00000X
Eyewear Supplier
18002670A/B
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000257711
ANTHEM BC/BS LAGRANGE
IN
01
—
000000257712
ANTHEM BC/BS TOPEKA
IN
01
—
000000635212
ANTHEM NWIELC KNOX
IN
01
—
1639177793
RICKY WEIDOW NPI
IN
05
—
200097680C
—
IN
05
—
200097680D
—
IN
05
—
200097680E
—
IN
01
—
2604633421
VISION SERVICE PLAN LAGRANGE
IN
01
—
2605932505
VISION SERVICE PLAN TOPEKA
IN
01
—
5742334109
VISION SERVICE PLAN SOUTH BEND
IN
Enumeration date
04/19/2007
Last updated
02/27/2010
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