Basic Information
| Provider Information | |||||||||
| NPI: | 1477961613 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA CLINICA DE LA RAZA, INC. | ||||||||
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| OtherOrganizationName: | FREMONT HIGH SCHOOL EPSDT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22210 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946232210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105352907 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4610 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946014618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105356200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2014 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5105354000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LA CLINICA DE LA RAZA, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.