Lifelong Medical Care
Organization Active NPI Geriatric Medicine (Family Medicine) Physician · Berkeley, CA
NPI 1689670002 · NPPES record last updated Oct 23, 2009
Key facts
- NPI
- 1689670002
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Geriatric Medicine (Family Medicine) Physician 207QG0300X
- License
- 140000191 (CA)
- Legal business name
- LIFELONG MEDICAL CARE
- Practice address
- 3260 Sacramento St
Berkeley, CA 94702-2739 - Phone
- (510) 428-4500
- NPI assigned
- Jun 21, 2005
- Organization subpart
- No
Authorized official
- Name
- Mr. Marty Lynch, N/A
- Title
- Ceo
- Phone
- (510) 981-4100
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 11
Practitioners 286
-
Nicole Atme-Bahrani, FNP
-
Mariam Attawia, NP
-
Jessica D Bigler Uhl, LCSW
-
Karen Carothers, MD
-
Ji Jill Chen, M.D.
-
Anya Desai, MD
-
Linda K. Frankel, M.D.
-
Douglas Frey, MSN, NP-C, FNP
-
Eric Arthur Fuller, DPM
-
Dana Gersten, MD
-
Michael Lee Goldrich, M.D.
-
Merry Beth Gong, M.D.
-
Andrea L. Green, MD
-
Zena E Herman, FNP
-
Manton Scott Hurd, N.P.
-
Amy Kane, M.D.
-
James Peter Keim, MSW, LCSW
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in CA
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
- Corporation · Non-profit
- Incorporated
- Jul 21, 1978 in CA
- Enrollment address
- 3260 Sacramento St
Berkeley, CA 94702-2739 - Related CCNs
- 051878
All disclosed owners & managing parties 15
| Name | Role | Since | Share |
|---|---|---|---|
| Jeanette L Alexich |
Corporate Director |
Sep 1, 2001 | 6.25% |
| Janet M Howley |
Corporate Officer |
Sep 1, 2001 | 6.25% |
| Kevin Williams |
Corporate Director |
Jan 1, 2007 | 6.25% |
| Georgia Lacy |
Corporate Officer |
Jan 1, 2003 | 6.25% |
| Martin Lynch |
Corporate Director |
Jul 1, 1996 | |
| Ronald Adler |
Corporate Officer |
Nov 4, 2004 | 6.25% |
| Patricia C Carson-Sussman |
Corporate Director |
Jan 1, 2005 | 6.25% |
| Dianna Chambers-Beamon |
Corporate Director |
Jan 1, 2007 | 6.25% |
| Gloria Flores-Garcia |
Corporate Director | Oct 1, 2005 | |
| Judith Turiel |
Corporate Director |
Dec 1, 1999 | 6.25% |
| Stephen Fleischer-Ihn |
Corporate Director |
May 7, 2018 | |
| Nancy Threatt |
Corporate Officer |
Aug 1, 2003 | 6.25% |
| James Johnson |
Corporate Director |
Mar 1, 2009 | 6.25% |
| Brent Copen |
Corporate Officer |
Jul 19, 2021 | |
| W-2 Managing Employee |
Jul 19, 2021 | ||
| Roberta Brooks |
Corporate Director |
Nov 1, 2007 | 6.25% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Adult Medicine Physician |
207QA0505X | 140000191 | CA | |
| Geriatric Medicine (Family Medicine) Physician |
207QG0300X | 140000191 | CA | Yes |
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
| Identifier | Type | State | Issuer |
|---|---|---|---|
| FHC70859F | Medicaid | CA |
Other names
- OVER SIXTY HEALTH CENTER
Other providers in Berkeley, CA
- Lifelong Medical Care
- Lifelong Medical Care
- Lifelong Medical Care
- Lifelong Medical Care
- Lifelong Medical Care
- Lifelong Medical Care
- Lifelong Medical Care
- Lifelong Medical Care
- Lifelong Medical Care
- Lifelong Medical Center
All providers in Berkeley, CA · Geriatric Medicine (Family Medicine) Physician in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 23, 2009. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.