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	171M00000X	Case Manager/Care Coordinator
2	207QA0505X	Adult Medicine Physician	020000503	CA
3	207V00000X	Obstetrics & Gynecology Physician	020000503	CA
4	208000000X	Pediatrics Physician	020000503	CA
5	207QA0000X	Adolescent Medicine (Family Medicine) Physician	020000503	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
2	HAP70635F	OTHER	CA	FAMILY PACT

General Provider Information

NPI Number	:	1720084163
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	:

Provider Business Practice Location Address
First Line	:	2031 6TH ST
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94710-2006
Country	:	US
Telephone Number	:	510-981-4200
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. MARTY LYNCH
Credential	:	N/A
Telephone Number	:	510-981-4100

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	04/04/2022

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Directions to “LIFELONG MEDICAL CARE ” Practice Location

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