=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841151925
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHAN-TASTIC EYE CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2025
-----------------------------------------------------
Last Update Date | 11/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 OVIEDO MALL BLVD
-----------------------------------------------------
City | OVIEDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32765-9348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-348-3026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1488 VIA SANGRO PL
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-6243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-435-3175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | BAO PHAN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 407-435-3175
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------