Healthcare Provider Details

I. General information

NPI: 1720243454
Provider Name (Legal Business Name): LA CLINICA DE LA RAZA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 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: 707-641-1900
  • Fax: 707-554-2294
Mailing address:
  • Phone: 510-535-4000
  • Fax: 510-535-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number110000270
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number05D1087668
License Number StateCA

VIII. Authorized Official

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