Basic Information
Provider Information | |||||||||
NPI: | 1154327138 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIFELONG MEDICAL CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LIFELONG MEDICAL CARE- EAST OAKLAND | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11247 | ||||||||
Address2: |   | ||||||||
City: | BERKELEY | ||||||||
State: | CA | ||||||||
PostalCode: | 947122247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5109814100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10700 MACARTHUR BLVD | ||||||||
Address2: | STE 14B | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946055260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5105634300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2005 | ||||||||
LastUpdateDate: | 03/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LYNCH | ||||||||
AuthorizedOfficialFirstName: | MARTY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5109814100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | N/A | ||||||||
NPICertificationDate: | 03/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   | 207QG0300X | 140000538 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | FHC70704F | 05 | CA |   | MEDICAID |