Basic Information
| Provider Information | |||||||||
| NPI: | 1427400167 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFELONG MEDICAL CARE | ||||||||
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| OtherOrganizationName: | LIFELONG EMERYVILLE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2344 6TH ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947102412 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4727 SAN PABLO AVE | ||||||||
| Address2: | ROOM B214 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946083035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109814100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2016 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | LYNCH | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5109814123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFELONG MEDICAL CARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.