Provider Demographics
NPI:1043495450
Name:LA CLINICA DEL PUEBLO, INC
Entity Type:Organization
Organization Name:LA CLINICA DEL PUEBLO, INC
Other - Org Name:ALCOHOL/SUBSTANCE ABUSE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOANIE
Authorized Official - Middle Name:CLEMENT
Authorized Official - Last Name:RODRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-464-0141
Mailing Address - Street 1:2831 15TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-4607
Mailing Address - Country:US
Mailing Address - Phone:202-462-4788
Mailing Address - Fax:202-250-3290
Practice Address - Street 1:2831 15TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-4607
Practice Address - Country:US
Practice Address - Phone:202-462-4788
Practice Address - Fax:202-250-3290
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CLINICA DEL PUEBLO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-03
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC037411700Medicaid