Healthcare Provider Details

I. General information

NPI: 1376931295
Provider Name (Legal Business Name): LIFELONG MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

386 14TH ST
OAKLAND CA
94612-3211
US

IV. Provider business mailing address

PO BOX 11247
BERKELEY CA
94712-2247
US

V. Phone/Fax

Practice location:
  • Phone: 510-981-4100
  • Fax:
Mailing address:
  • Phone: 510-981-4122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MARTIN LYNCH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PHD
Phone: 510-981-4123