Provider Demographics
NPI:1427070374
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: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:510-238-5400
Mailing Address - Fax:510-238-8015
Practice Address - Street 1:1030 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-3730
Practice Address - Country:US
Practice Address - Phone:510-238-5400
Practice Address - Fax:510-238-8015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CLINICA DE LA RAZA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-23
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA140000708261QF0400X
CACLIA05D0921215291U00000X
CADEA58952403336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC11991FMedicaid
CAFHC11991FMedicaid
CAZZZ79046ZMedicare PIN
CAZZZ79046ZMedicare PIN