Provider Demographics
NPI:1144336181
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:PO BOX 22210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94623-2210
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4189
Practice Address - Street 1:3451 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3425
Practice Address - Country:US
Practice Address - Phone:510-535-4000
Practice Address - Fax:510-535-4189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA036347261QR0200X
CACLIA0500601766291U00000X
CAPHY464743336C0002X
CA140000675261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No291U00000XLaboratoriesClinical Medical Laboratory
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC71021FMedicaid
CALAB01766FMedicaid
CA551975Medicare Oscar/Certification
CALAB01766FMedicaid
CA55-1975OtherMEDICARE PART A
CAZZZ29799ZOtherMEDICARE PART B