Healthcare Provider Details

I. General information

NPI: 1124488002
Provider Name (Legal Business Name): LIFELONG MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2344 6TH ST
BERKELEY CA
94710-2412
US

IV. Provider business mailing address

2344 6TH ST
BERKELEY CA
94710-2412
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number95003280
License Number StateCA

VIII. Authorized Official

Name: MEGAN SMITH
Title or Position: CREDENTIAL COORDINATOR
Credential:
Phone: 510-981-4174