Provider Demographics
NPI:1407973043
Name:LIFELONG MEDICAL CARE
Entity Type:Organization
Organization Name:LIFELONG MEDICAL CARE
Other - Org Name:LIFELONG WILLIAM JENKINS HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:VLIET
Authorized Official - Suffix:
Authorized Official - Credentials:
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:510-981-4100
Mailing Address - Fax:510-981-4193
Practice Address - Street 1:150 HARBOUR WAY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3554
Practice Address - Country:US
Practice Address - Phone:510-237-9537
Practice Address - Fax:510-981-4191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFELONG MEDICAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-26
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000122261QC1500X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC71108FMedicaid
051041Medicare ID - Type Unspecified