NPIMap

Organization Active NPI

Lifelong Medical Care

Doing business as Over Sixty Health Center

  • Geriatric Medicine (Family Medicine) Physician
  • Berkeley, CA
National Provider Identifier
1689670002
Registry record updated Oct 23, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Medicine (Family Medicine) PhysicianTaxonomy code 207QG0300X
License
140000191 Issued in CA
Legal business name
LIFELONG MEDICAL CARE
Doing business as
Over Sixty Health Center
Practice address
3260 Sacramento St
Berkeley, CA 94702-2739
Phone
(510) 428-4500
NPI assigned
Jun 21, 2005
Last updated
Oct 23, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 23, 2009

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

Authorized official

Name
Mr. Marty Lynch, N/A
Title
Ceo
Phone
(510) 981-4100

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Adult Medicine Physician 207QA0505X 140000191 CA
Geriatric Medicine (Family Medicine) Physician 207QG0300X 140000191 CA Primary

Addresses

Primary practice location

3260 Sacramento St
Berkeley, CA 94702-2739

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
FHC70859FMedicaidCA

Other names 1

  • OVER SIXTY HEALTH CENTER Doing business as

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
Practice locations: Rodeo, CA; Richmond, CA; Oakland, CA; Berkeley, CA
O20111025000143 CA Part A Provider - Federally Qualified Health Center (FQHC) 2062304538 Practice locations: Berkeley, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1689670002. Details of each certification follow.

Federally qualified health center certification: CCN 551871

Legal name
LIFELONG MEDICAL CARE
Doing business as
LIFELONG MEDICAL CARE OVER SIXTY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 28, 2000
Last certification
Apr 28, 2000
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jul 21, 1978 in CA
Enrollment address
3260 Sacramento St
Berkeley, CA 94702-2739
Related CCNs
051878

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.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 15

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

NameRoleSinceShare
Jeanette L Alexich Individual Corporate DirectorBoard of Director Sep 1, 2001 6.25%
Janet M Howley Individual Corporate OfficerPast Chair Sep 1, 2001 6.25%
Kevin Williams Individual Corporate DirectorBoard of Director Jan 1, 2007 6.25%
Georgia Lacy Individual Corporate OfficerChair Jan 1, 2003 6.25%
Martin Lynch Individual Corporate DirectorCeo/Executive Director Jul 1, 1996
Ronald Adler Individual Corporate OfficerVice Chair Nov 4, 2004 6.25%
Patricia C Carson-Sussman Individual Corporate DirectorBoard of Director Jan 1, 2005 6.25%
Dianna Chambers-Beamon Individual Corporate DirectorBoard of Director Jan 1, 2007 6.25%
Gloria Flores-Garcia Individual Corporate Director Oct 1, 2005
Judith Turiel Individual Corporate DirectorBoard of Director Dec 1, 1999 6.25%
Stephen Fleischer-Ihn Individual Corporate DirectorDirector of Legal Services May 7, 2018
Nancy Threatt Individual Corporate OfficerSecretary Aug 1, 2003 6.25%
James Johnson Individual Corporate DirectorBoard of Director Mar 1, 2009 6.25%
Brent Copen Individual Corporate OfficerCfo Jul 19, 2021
W-2 Managing EmployeeCfo Jul 19, 2021
Roberta Brooks Individual Corporate DirectorBoard of Director Nov 1, 2007 6.25%

Practitioners & affiliated clinicians

Practitioners 266

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 266

NPI Registry JSON

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

{
    "created_epoch": "1119312000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1256256000000",
    "number": "1689670002",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3260 SACRAMENTO ST",
            "city": "BERKELEY",
            "state": "CA",
            "postal_code": "947022739",
            "telephone_number": "510-428-4500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFELONG MEDICAL CARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-21",
        "last_updated": "2009-10-23",
        "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",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "N/A"
    },
    "taxonomies": [
        {
            "code": "207QA0505X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Adult Medicine",
            "state": "CA",
            "license": "140000191",
            "primary": false
        },
        {
            "code": "207QG0300X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Geriatric Medicine",
            "state": "CA",
            "license": "140000191",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC70859F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "OVER SIXTY HEALTH CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Berkeley, CA

Sources for this page

Verify at the official NPI Registry.