Healthcare Provider Details

I. General information

NPI: 1720084163
Provider Name (Legal Business Name): LIFELONG MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2031 6TH ST
BERKELEY CA
94710-2006
US

IV. Provider business mailing address

PO BOX 11247
BERKELEY CA
94712-2247
US

V. Phone/Fax

Practice location:
  • Phone: 510-981-4200
  • Fax:
Mailing address:
  • Phone: 510-981-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number020000503
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number020000503
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number020000503
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number020000503
License Number StateCA

VIII. Authorized Official

Name: MR. MARTY LYNCH
Title or Position: CEO
Credential: N/A
Phone: 510-981-4100