Healthcare Provider Details

I. General information

NPI: 1992863096
Provider Name (Legal Business Name): LA CLINICA DE LA RAZA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 HOSPITAL DR
VALLEJO CA
94589-2517
US

IV. Provider business mailing address

PO BOX 22210
OAKLAND CA
94623-2210
US

V. Phone/Fax

Practice location:
  • Phone: 707-645-7316
  • Fax: 707-645-0426
Mailing address:
  • Phone: 510-535-4000
  • Fax: 510-535-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number05D1057049
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number550000257
License Number StateCA

VIII. Authorized Official

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