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General NPI Number Information
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NPI Number | 1831443563
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Entity Type | Organization
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Legal Business Name | LIFELONG MEDICAL CARE - EASTMONT
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Dates
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Enumeration Date | 11/02/2012
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Last Update Date | 11/02/2012
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Provider Practice Location Address
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Address Line | 7200 BANCROFT AVE SUITE 125A
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City | OAKLAND
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State | CA
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Zip | 94605-2403
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Country | US
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Telephone | 510-430-8740
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 11247
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City | BERKELEY
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State | CA
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Zip | 94712-2247
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Country | US
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Telephone | 510-981-4122
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Fax |
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. RICK CLARK
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Credential |
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Telephone | 510-981-4122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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