1174740682 NPI number — RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.

Table of content: (NPI 1174740682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174740682 NPI number — RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAISSANCE OCULAR DISEASE AND TRAUMA FOUNDATION, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174740682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 W WAYNE ST
Provider Second Line Business Mailing Address:
PO BOX 150
Provider Business Mailing Address City Name:
LAGRANGE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46761-1850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-463-3421
Provider Business Mailing Address Fax Number:
260-463-7347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 W WAYNE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46761-1850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-463-3421
Provider Business Practice Location Address Fax Number:
260-463-7347
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18002670A/B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: 18002670A/B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2605932505 . This is a "VISION SERVICE PLAN TOPEKA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 5742334109 . This is a "VISION SERVICE PLAN SOUTH BEND" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200097680D , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2604633421 . This is a "VISION SERVICE PLAN LAGRANGE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000257711 . This is a "ANTHEM BC/BS LAGRANGE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000257712 . This is a "ANTHEM BC/BS TOPEKA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000635212 . This is a "ANTHEM NWIELC KNOX" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200097680E , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1639177793 . This is a "RICKY WEIDOW NPI" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200097680C , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com