NPIMap

Organization Active NPI

Lifelong Medical Care

  • Community Health Clinic/Center
  • Richmond, CA
National Provider Identifier
1407973043
Registry record updated Jan 19, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health Clinic/CenterTaxonomy code 261QC1500X
License
550000122 Issued in CA
Legal business name
LIFELONG MEDICAL CARE
Practice address
150 Harbour Way
Richmond, CA 94801-3554
Phone
(510) 237-9537
Fax
(510) 981-4191
NPI assigned
Mar 26, 2007
Last updated
Jan 19, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
LIFELONG MEDICAL CAREAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 19, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
David B. Vliet
Title
Ceo
Phone
(510) 981-4123

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X 550000122 CA Primary
Dental Clinic/Center 261QD0000X

Addresses

Primary practice location

150 Harbour Way
Richmond, CA 94801-3554

Mailing address

PO Box 11247
Berkeley, CA 94712-2247
Phone (510) 981-4100

Other identifiers 1

IdentifierTypeStateIssuer
FHC71108FMedicaidCA

Other names 1

  • LifeLong William Jenkins Health Center Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050713000704 CA Part B Supplier - Clinic/Group Practice 2062304538 Receives reassigned benefits from 260 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rodeo, CA; Richmond, CA; Oakland, CA; Berkeley, CA
O20120425000294 CA Part A Provider - Federally Qualified Health Center (FQHC) 2062304538 Practice locations: Richmond, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1407973043. Details of each certification follow.

Federally qualified health center certification: CCN 051041

Legal name
LIFELONG MEDICAL CARE
Doing business as
LIFELONG BROOKSIDE COMMUNITY HEALTH CENTER RICHMOND
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 23, 2005
Last certification
Nov 23, 2005
Ownership / control type
For profit – corporation
Most recent change of ownership
Apr 1, 2012 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1996 in CA
Enrollment address
1030 Nevin Ave
Richmond, CA 94801-3122

Other NPIs with the same Medicare PAC ID 11

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D2180345Lifelong William Jenkins Health Center150 Harbour Way, Richmond, CA 94801Provider-performed microscopyMar 10, 2028

National Provider Directory

National Provider Directory
Tax ID family
Lifelong Medical Center44 organizations share this tax ID, including this one
Part of
Lifelong Medical Center

Other organizations with this tax ID 43

Organizations that report the same tax identification number in the National Provider Directory.

View all 43

Locations

2023 Vale Rd
Ste 107
San Pablo, CA 94806
Phone (510) 215-9092

Ownership & related parties

All disclosed owners & managing parties 18

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Brenda a Shipp Individual Corporate OfficerCoo/Deputy Officer May 7, 2007
Jeanette L Alexich Individual Corporate DirectorBoard of Directors Sep 1, 2001 6.67%
Cheryl Maier Individual Corporate DirectorDirector Feb 10, 1997
Janet M Howley Individual Corporate DirectorDirector Sep 1, 2001
Kevin Williams Individual Corporate DirectorBoard of Directors Jan 1, 2007 6.67%
Lucinda Brannon Individual Corporate DirectorDirector Nov 2, 2011
Georgia Lacy Individual Corporate DirectorDirector Jan 1, 2003
Martin Lynch Individual Corporate DirectorDirector Jul 1, 1996
Ronald Adler Individual Corporate DirectorDirector Nov 4, 2040
Patricia C Carson-Sussman Individual Corporate DirectorBoard of Directors Jan 1, 2005 6.67%
Dianna Chambers-Beamon Individual Corporate DirectorBoard of Directors Jan 1, 2007 6.67%
Gloria Flores-Garcia Individual Corporate DirectorBoard of Directors Oct 1, 2005 6.67%
Judith Turiel Individual Corporate DirectorBoard of Directors Dec 1, 1990 6.67%
Stephen Fleischer-Ihn Individual Corporate DirectorDirector of Legal Services May 7, 2018
Nancy Threatt Individual Corporate OfficerSecretary Aug 1, 2003 6.67%
James Johnson Individual Corporate DirectorBoard of Directors Mar 1, 2009 6.67%
Brent Copen Individual Corporate OfficerCfo Jul 19, 2021
W-2 Managing EmployeeCfo Jul 19, 2021
Roberta Brooks Individual Corporate DirectorDirector Nov 1, 2007

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174867200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611014400000",
    "number": "1407973043",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 11247",
            "city": "BERKELEY",
            "state": "CA",
            "postal_code": "947122247",
            "telephone_number": "510-981-4100",
            "fax_number": "510-981-4193"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "150 HARBOUR WAY",
            "city": "RICHMOND",
            "state": "CA",
            "postal_code": "948013554",
            "telephone_number": "510-237-9537",
            "fax_number": "510-981-4191"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFELONG MEDICAL CARE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LIFELONG MEDICAL CARE",
        "enumeration_date": "2007-03-26",
        "last_updated": "2021-01-19",
        "certification_date": "2021-01-19",
        "status": "A",
        "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"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "CA",
            "license": "550000122",
            "primary": true
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC71108F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LifeLong William Jenkins Health Center",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Richmond, CA

Sources for this page

Verify at the official NPI Registry.