Provider Demographics
NPI:1851788004
Name:LA CLINICA DE LA RAZA
Entity Type:Organization
Organization Name:LA CLINICA DE LA RAZA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SITE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:510-535-3301
Mailing Address - Street 1:1040 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-1832
Mailing Address - Country:US
Mailing Address - Phone:510-325-1325
Mailing Address - Fax:
Practice Address - Street 1:3451 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3463
Practice Address - Country:US
Practice Address - Phone:510-535-3301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28770124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty