Provider Demographics
NPI:1376931295
Name:LIFELONG MEDICAL CARE
Entity Type:Organization
Organization Name:LIFELONG MEDICAL CARE
Other - Org Name:LIFELONG TRUST HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:510-981-4123
Mailing Address - Street 1:PO BOX 11247
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94712-2247
Mailing Address - Country:US
Mailing Address - Phone:510-981-4122
Mailing Address - Fax:
Practice Address - Street 1:386 14TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3211
Practice Address - Country:US
Practice Address - Phone:510-981-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFELONG MEDICAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-30
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA751194Medicare Oscar/Certification