Healthcare Provider Details

I. General information

NPI: 1730476110
Provider Name (Legal Business Name): LA CLINICA DE LA RAZA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
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
94623-2322
US

V. Phone/Fax

Practice location:
  • Phone: 510-238-5400
  • Fax: 510-238-8015
Mailing address:
  • Phone: 510-535-4000
  • Fax: 510-535-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUSAN MOORE
Title or Position: CFO
Credential:
Phone: 510-535-2915