1407973043 NPI number — LIFELONG MEDICAL CARE

Table of content: (NPI 1407973043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407973043 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:
Provider Other Organization Name Type Code:
6
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:
1407973043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2021
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:
510-981-4193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 HARBOUR WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94801-3554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-237-9537
Provider Business Practice Location Address Fax Number:
510-981-4191
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VLIET
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
510-981-4123

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1500X , with the licence number: 550000122 , 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: FHC71108F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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