Provider Demographics
NPI:1689670002
Name:LIFELONG MEDICAL CARE
Entity Type:Organization
Organization Name:LIFELONG MEDICAL CARE
Other - Org Name:OVER SIXTY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:510-981-4100
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:
Practice Address - Street 1:3260 SACRAMENTO ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-2739
Practice Address - Country:US
Practice Address - Phone:510-428-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140000191207QA0505X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70859FMedicaid
CA551871Medicare ID - Type UnspecifiedPART B UGS
CAFHC70859FMedicaid