Provider Demographics
NPI:1578834164
Name:LA CLINICA DE LA RAZA, INC.
Entity Type:Organization
Organization Name:LA CLINICA DE LA RAZA, INC.
Other - Org Name:LA CLINICA OAKLEY
Other - Org Type:Doing Business As
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 1:2021 MAIN ST
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:CA
Practice Address - Zip Code:94561-3302
Practice Address - Country:US
Practice Address - Phone:925-776-8200
Practice Address - Fax:925-776-8260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550002122261QF0400X
CLIA05D2036282291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1578834164Medicaid
CAZZZ79046ZMedicare PIN
CA55-1121OtherMEDICARE CMS CERTIFICATION NUMBER