Provider Demographics
NPI:1780606632
Name:LA CLINICA DE LA RAZA INC
Entity type:Organization
Organization Name:LA CLINICA DE LA RAZA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-535-4000
Mailing Address - Street 1:1515 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2322
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4189
Practice Address - Street 1:2920A SONOMA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-3879
Practice Address - Country:US
Practice Address - Phone:707-558-2000
Practice Address - Fax:707-644-3507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Not Answered261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70833FMedicaid