Provider Demographics
NPI:1093969420
Name:LIFELONG MEDICAL CARE
Entity Type:Organization
Organization Name:LIFELONG MEDICAL CARE
Other - Org Name:LIFELONG MEDICAL CARE-DOWNTOWN OAKLAND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-451-4270
Mailing Address - Street 1:616 16TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1205
Mailing Address - Country:US
Mailing Address - Phone:510-451-4270
Mailing Address - Fax:
Practice Address - Street 1:616 16TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1205
Practice Address - Country:US
Practice Address - Phone:510-451-4270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFELONG MEDICAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-12
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA051016Medicare Oscar/Certification