Healthcare Provider Details

I. General information

NPI: 1689670002
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: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3260 SACRAMENTO ST
BERKELEY CA
94702-2739
US

IV. Provider business mailing address

PO BOX 11247
BERKELEY CA
94712-2247
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-4500
  • Fax:
Mailing address:
  • Phone: 510-981-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number140000191
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number140000191
License Number StateCA

VIII. Authorized Official

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