Provider Demographics
NPI:1720243454
Name:LA CLINICA DE LA RAZA, INC.
Entity Type:Organization
Organization Name:LA CLINICA DE LA RAZA, INC.
Other - Org Name:LA CLINICA NORTH VALLEJO
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:510-535-2915
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 1:220 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2517
Practice Address - Country:US
Practice Address - Phone:707-641-1900
Practice Address - Fax:707-554-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000270261QF0400X
CA05D1087668291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720243454Medicaid
CA1720243454Medicaid
CA051157Medicare Oscar/Certification