NPIMap

Organization Active NPI

Lifelong Medical Care

Doing business as LifeLong Brookside Community Health Center San Pablo

  • Community Health Clinic/Center
  • San Pablo, CA
National Provider Identifier
1487696191
Registry record updated Jun 6, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health Clinic/CenterTaxonomy code 261QC1500X
Legal business name
LIFELONG MEDICAL CARE
Doing business as
LifeLong Brookside Community Health Center San Pablo
Practice address
2023 Vale Rd
Ste 107
San Pablo, CA 94806-3891
Phone
(510) 215-9092
Fax
(510) 412-9867
NPI assigned
Jun 10, 2006
Last updated
Jun 6, 2012By the provider in NPPES
Organization subpart
Yes
Parent organization
LIFELONG MEDICAL CAREAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 6, 2012

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

Authorized official

Name
Marty Lynch
Title
Ceo
Phone
(510) 981-4100

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X Primary

Addresses

Primary practice location

2023 Vale Rd
Ste 107
San Pablo, CA 94806-3891

Mailing address

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

Other names 1

  • LifeLong Brookside Community Health Center San Pablo Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120424000293 WI Part A Provider - Federally Qualified Health Center (FQHC) 2062304538 Practice locations: San Pablo, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1487696191. Details of each certification follow.

Federally qualified health center certification: CCN 551837

Legal name
LIFELONG MEDICAL CARE
Doing business as
LIFELONG BROOKSIDE COMMUNITY HEALTH CENTER SAN PABLO
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 2, 1997
Last certification
Jan 2, 1997
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
2023 Vale Rd 107
San Pablo, CA 94806-3891

Other NPIs with the same Medicare PAC ID 11

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

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

2344 6th St
Berkeley, CA 94710
Phone (510) 981-3203

Ownership & related parties

All disclosed owners & managing parties 20

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

NameRoleSinceShare
Phil Kamlarz Individual Corporate Director Jun 1, 2016
Jeanette L Alexich Individual Corporate DirectorBoard of Director Sep 1, 2001 6.67%
John Jenkins Individual Corporate Director Jun 1, 2012
Janet M Howley Individual Corporate DirectorDirector Sep 1, 2001
Edgar Quiroz Individual Corporate Director May 1, 2015
Kevin Williams Individual Corporate DirectorBoard of Director Jan 1, 2007 6.67%
Nance Rosencranz Individual Corporate Director Jan 31, 2005
Georgia Lacy Individual Corporate OfficerChair Jan 1, 2003 6.67%
Martin Lynch Individual Corporate DirectorCeo/Exceutive Director Jul 1, 1996
Ronald Adler Individual Corporate DirectorDirector Nov 4, 2004
Patricia C Carson-Sussman Individual Corporate DirectorBoard of Director Jan 1, 2005 6.67%
Gloria Flores-Garcia Individual Corporate DirectorBoard of Director Oct 1, 2005 6.67%
Judith Turiel Individual Corporate DirectorBoard of Director Dec 1, 1980 6.67%
Stephen Fleischer-Ihn Individual Corporate DirectorDirector of Legal Services May 7, 2018
Patricia Espinosa Individual Corporate Officer Nov 1, 2007
Nancy Threatt Individual Corporate OfficerSecretary Aug 1, 2003 6.67%
James Johnson Individual Corporate DirectorBoard of Director Mar 1, 2009 6.67%
Margaret Elizabeth Schilling Individual Corporate Director Sep 1, 2001
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 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1149897600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1338940800000",
    "number": "1487696191",
    "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": "2023 VALE RD",
            "address_2": "STE 107",
            "city": "SAN PABLO",
            "state": "CA",
            "postal_code": "948063891",
            "telephone_number": "510-215-9092",
            "fax_number": "510-412-9867"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFELONG MEDICAL CARE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LIFELONG MEDICAL CARE",
        "enumeration_date": "2006-06-10",
        "last_updated": "2012-06-06",
        "status": "A",
        "authorized_official_last_name": "LYNCH",
        "authorized_official_first_name": "MARTY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "510-981-4100"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LifeLong Brookside Community Health Center San Pablo",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Pablo, CA

Sources for this page

Verify at the official NPI Registry.