Provider Demographics
NPI:1780032128
Name:LIFELONG MEDICAL CARE
Entity Type:Organization
Organization Name:LIFELONG MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HENLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-563-4300
Mailing Address - Street 1:10700 MACARTHUR BLVD
Mailing Address - Street 2:SUITE 14 B
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-5298
Mailing Address - Country:US
Mailing Address - Phone:510-932-1034
Mailing Address - Fax:510-563-4387
Practice Address - Street 1:10700 MACARTHUR BLVD
Practice Address - Street 2:SUITE 14 B
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-5298
Practice Address - Country:US
Practice Address - Phone:510-932-1034
Practice Address - Fax:510-563-4387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336201261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health