Basic Information
| Provider Information | |||||||||
| NPI: | 1487696191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFELONG MEDICAL CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIFELONG BROOKSIDE COMMUNITY HEALTH CENTER SAN PABLO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11247 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947122247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109814100 | ||||||||
| FaxNumber: | 5109814193 | ||||||||
| Practice Location | |||||||||
| Address1: | 2023 VALE RD | ||||||||
| Address2: | STE 107 | ||||||||
| City: | SAN PABLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948063891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102159092 | ||||||||
| FaxNumber: | 5104129867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 06/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | LYNCH | ||||||||
| AuthorizedOfficialFirstName: | MARTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5109814100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFELONG MEDICAL CARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.