Healthcare Provider Details

I. General information

NPI: 1124035159
Provider Name (Legal Business Name): LA CLINICA DE LA RAZA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060B E 9TH ST
OAKLAND CA
94601-2322
US

IV. Provider business mailing address

PO BOX 22210
OAKLAND CA
94623-2210
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-5500
  • Fax: 510-535-4349
Mailing address:
  • Phone: 510-535-4000
  • Fax: 510-535-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number140000708
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. PATRICIA AGUILERA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 510-535-2915