Provider Demographics
NPI:1831569680
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:NUTRITIONIST LL
Authorized Official - Prefix:MRS
Authorized Official - First Name:BELKYS
Authorized Official - Middle Name:M
Authorized Official - Last Name:GERONIMO
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:510-535-2965
Mailing Address - Street 1:POBOX 2210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94623
Mailing Address - Country:US
Mailing Address - Phone:510-535-2965
Mailing Address - Fax:510-535-4128
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:510-535-2965
Practice Address - Fax:510-535-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL642175261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service