Healthcare Provider Details

I. General information

NPI: 1407973043
Provider Name (Legal Business Name): LIFELONG MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 HARBOUR WAY
RICHMOND CA
94801-3554
US

IV. Provider business mailing address

PO BOX 11247
BERKELEY CA
94712-2247
US

V. Phone/Fax

Practice location:
  • Phone: 510-237-9537
  • Fax: 510-981-4191
Mailing address:
  • Phone: 510-981-4100
  • Fax: 510-981-4193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number550000122
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID B. VLIET
Title or Position: CEO
Credential:
Phone: 510-981-4123