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	291U00000X	Clinical Medical Laboratory	CLIA0500921212	CA
2	261QF0400X	Federally Qualified Health Center (FQHC)	550000036	CA

Other Identifiers

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

General Provider Information

NPI Number	:	1235245275
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	:	1515 FRUITVALE AVE
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94601-2322
Country	:	US
Telephone Number	:	510-535-6300
Fax Number	:	510-535-4019

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	:	10/17/2019

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