=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528080470
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA CLINICA DE LA RAZA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 10/29/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 339 E LELAND RD
-----------------------------------------------------
City | PITTSBURG
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94565-4911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-431-1250
-----------------------------------------------------
Fax | 925-431-1252
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 FRUITVALE AVE
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94601-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-535-4000
-----------------------------------------------------
Fax | 510-535-4189
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MRS. JANE GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-535-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------