Healthcare Provider Details

I. General information

NPI: 1629379896
Provider Name (Legal Business Name): LA CLINICA DE LA RAZA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415-1423 FRUITVALE AVE
OAKLAND CA
94601-2320
US

IV. Provider business mailing address

PO BOX 22210
OAKLAND CA
94623-2210
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-8400
  • Fax: 510-535-8460
Mailing address:
  • Phone: 510-535-4000
  • Fax: 510-535-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCA

VIII. Authorized Official

Name: JANE GARCIA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 510-535-4000