Provider Demographics
NPI:1568875482
Name:V. PHAN OPTOMETRIC PROF CORP
Entity Type:Organization
Organization Name:V. PHAN OPTOMETRIC PROF CORP
Other - Org Name:PLACENTIA FAMILY OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:VAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-234-3080
Mailing Address - Street 1:949 W MERCED TRAIL ROAD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865
Mailing Address - Country:US
Mailing Address - Phone:714-234-3080
Mailing Address - Fax:714-792-3603
Practice Address - Street 1:1525 N PLACENTIA AVE
Practice Address - Street 2:UNIT A
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-2334
Practice Address - Country:US
Practice Address - Phone:714-792-3619
Practice Address - Fax:714-792-3603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13193 T305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization