MEDICARE: LA CLINICA DE LA RAZA INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	140000171	CA
2	261QF0400X	Federally Qualified Health Center (FQHC)	140000171	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ29799Z	OTHER	CA	MEDICARE PART B
2	05-1063	OTHER	CA	MEDICARE PART A

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174639116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA CLINICA DE LA RAZA INC

Provider Business Mailing Address
First Line	:	PO BOX 22210
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94623-2210
Country	:	US
Telephone Number	:	510-535-4000
Fax Number	:	510-535-4189

Provider Business Practice Location Address
First Line	:	1501 FRUITVALE AVE
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94601-2322
Country	:	US
Telephone Number	:	510-535-6200
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MS. JANE GARCIA
Credential	:
Telephone Number	:	510-535-4000

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	04/21/2023

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Directions to “LA CLINICA DE LA RAZA INC ” Practice Location

Language	Start Address	Practice Location

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