Healthcare Provider Details

I. General information

NPI: 1073405429
Provider Name (Legal Business Name): LIFELONG MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 UNIVERSITY AVE
BERKELEY CA
94710-2044
US

IV. Provider business mailing address

2344 6TH ST
BERKELEY CA
94710-2412
US

V. Phone/Fax

Practice location:
  • Phone: 916-749-6192
  • Fax:
Mailing address:
  • Phone: 916-749-6192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRENT COPEN
Title or Position: CFO
Credential:
Phone: 610-918-4122