1013913300 NPI number — LIFELONG MEDICAL CARE

Table of content: (NPI 1013913300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013913300 NPI number — LIFELONG MEDICAL CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFELONG MEDICAL CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIFELONG DENTAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013913300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94712-2247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-981-4100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1860 ALCATRAZ AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94703-2715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-653-8500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LYNCH
Authorized Official First Name:
MARTY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
510-981-4100

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FHC70239F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".