Provider Demographics
NPI:1215485396
Name:LA CLINICA DEL PUEBLO
Entity type:Organization
Organization Name:LA CLINICA DEL PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOANIE
Authorized Official - Middle Name:CLEMENT
Authorized Official - Last Name:RODRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-464-0141
Mailing Address - Street 1:2831 15TH STREET NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009
Mailing Address - Country:US
Mailing Address - Phone:202-462-4788
Mailing Address - Fax:
Practice Address - Street 1:3166 MOUNT PLEASANT ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010
Practice Address - Country:US
Practice Address - Phone:202-462-4788
Practice Address - Fax:202-667-3706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC52194XXXX650001047261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC85518500Medicaid
DC037411700Medicaid