Healthcare Provider Details

I. General information

NPI: 1013085778
Provider Name (Legal Business Name): LA CLINICA DE LA RAZA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 04/30/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 BROADWAY
OAKLAND CA
94611-4612
US

IV. Provider business mailing address

PO BOX 22210
OAKLAND CA
94623-2210
US

V. Phone/Fax

Practice location:
  • Phone: 510-879-1907
  • Fax: 510-879-1999
Mailing address:
  • Phone: 510-535-4000
  • Fax: 510-535-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number550000169
License Number StateCA

VIII. Authorized Official

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