Healthcare Provider Details

I. General information

NPI: 1093969420
Provider Name (Legal Business Name): LIFELONG MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 16TH ST SUITE 1
OAKLAND CA
94612-1205
US

IV. Provider business mailing address

616 16TH ST SUITE 1
OAKLAND CA
94612-1205
US

V. Phone/Fax

Practice location:
  • Phone: 510-451-4270
  • Fax:
Mailing address:
  • Phone: 510-451-4270
  • 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: MARTY LYNCH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 510-451-4270