Healthcare Provider Details

I. General information

NPI: 1427070374
Provider Name (Legal Business Name): LA CLINICA DE LA RAZA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 04/06/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 INTERNATIONAL BLVD
OAKLAND CA
94606-3730
US

IV. Provider business mailing address

PO BOX 22210
OAKLAND CA
94623-2210
US

V. Phone/Fax

Practice location:
  • Phone: 510-238-5400
  • Fax: 510-238-8015
Mailing address:
  • Phone: 510-238-5400
  • Fax: 510-238-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLIA05D0921215
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberDEA5895240
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number140000708
License Number StateCA

VIII. Authorized Official

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