Provider Demographics
NPI:1124035159
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:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUILERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-535-2915
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 1:3060B E 9TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2322
Practice Address - Country:US
Practice Address - Phone:510-535-5500
Practice Address - Fax:510-535-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
CA140000708261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC71063FMedicaid
CAFHC71063FMedicaid
CA051066Medicare Oscar/Certification
CA051066Medicare PIN