Provider Demographics
NPI:1164588133
Name:EXPRESS LENS LAB, INC.
Entity Type:Organization
Organization Name:EXPRESS LENS LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GOLDSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-545-1024
Mailing Address - Street 1:17150 NEWHOPE ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4250
Mailing Address - Country:US
Mailing Address - Phone:714-545-1024
Mailing Address - Fax:714-556-2026
Practice Address - Street 1:17150 NEWHOPE ST
Practice Address - Street 2:SUITE 305
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4250
Practice Address - Country:US
Practice Address - Phone:714-545-1024
Practice Address - Fax:714-556-2026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19209332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ772534Medicaid
NM88272567Medicaid