Provider Demographics
NPI:1972525822
Name:LA CLINICA DE LA RAZA INC
Entity Type:Organization
Organization Name:LA CLINICA DE LA RAZA INC
Other - Org Name:LA CLINICA PITTSBURG - MEDICAL
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 1:2240 GLADSTONE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:PITTSBURG
Practice Address - State:CA
Practice Address - Zip Code:94565-5126
Practice Address - Country:US
Practice Address - Phone:925-431-1259
Practice Address - Fax:925-431-1257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140000584261QF0400X
CA05D0954154291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70816FMedicaid
CAZZZ29799ZMedicare PIN
CA551976Medicare Oscar/Certification
CAHAP70816FOtherFPACT