Provider Demographics
NPI:1487696191
Name:LIFELONG MEDICAL CARE
Entity type:Organization
Organization Name:LIFELONG MEDICAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-981-4100
Mailing Address - Street 1:PO BOX 11247
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94712-2247
Mailing Address - Country:US
Mailing Address - Phone:510-981-4100
Mailing Address - Fax:510-981-4193
Practice Address - Street 1:2023 VALE RD
Practice Address - Street 2:STE 107
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3891
Practice Address - Country:US
Practice Address - Phone:510-215-9092
Practice Address - Fax:510-412-9867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFELONG MEDICAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-10
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
F88997Medicare UPIN
E32511Medicare UPIN
CAH76589Medicare UPIN
F95254Medicare UPIN
CA551837Medicare ID - Type Unspecified