Provider Demographics
NPI:1699029967
Name:2020 LENS OPTICAL
Entity Type:Organization
Organization Name:2020 LENS OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:ROMEO
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:562-261-7542
Mailing Address - Street 1:12345 MOUNTAIN AVE
Mailing Address - Street 2:SUITE X
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2783
Mailing Address - Country:US
Mailing Address - Phone:909-628-4222
Mailing Address - Fax:909-628-6555
Practice Address - Street 1:12345 MOUNTAIN AVE
Practice Address - Street 2:SUITE X
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2783
Practice Address - Country:US
Practice Address - Phone:909-628-4222
Practice Address - Fax:909-628-6555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37867305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization