Provider Demographics
NPI:1699029330
Name:LIFELONG MEDICAL CARE RICHMOND CLINIC
Entity Type:Organization
Organization Name:LIFELONG MEDICAL CARE RICHMOND CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-981-4122
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:510-215-5001
Mailing Address - Fax:510-215-1115
Practice Address - Street 1:2400 NEVIN AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-1700
Practice Address - Country:US
Practice Address - Phone:510-215-5001
Practice Address - Fax:510-215-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)