MEDICARE: LIFELONG MEDICAL CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center
2	261QC1500X	Community Health Clinic/Center	550000122	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407973043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFELONG MEDICAL CARE

Provider Business Mailing Address
First Line	:	PO BOX 11247
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94712-2247
Country	:	US
Telephone Number	:	510-981-4100
Fax Number	:	510-981-4193

Provider Business Practice Location Address
First Line	:	150 HARBOUR WAY
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94801-3554
Country	:	US
Telephone Number	:	510-237-9537
Fax Number	:	510-981-4191

Authorized Official
Title or Position	:	CEO
Name	:	DAVID B. VLIET
Credential	:
Telephone Number	:	510-981-4123

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	01/19/2021

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Directions to “LIFELONG MEDICAL CARE ” Practice Location

Language	Start Address	Practice Location

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