Basic Information
Provider Information | |||||||||
NPI: | 1538181482 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LA CLINICA DE LA RAZA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LA CLINICA MONUMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22210 | ||||||||
Address2: |   | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946232210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5105354000 | ||||||||
FaxNumber: | 5105354189 | ||||||||
Practice Location | |||||||||
Address1: | 2000 SIERRA ROAD | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | CA | ||||||||
PostalCode: | 945182905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9253632000 | ||||||||
FaxNumber: | 9253562792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2006 | ||||||||
LastUpdateDate: | 01/28/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARCIA | ||||||||
AuthorizedOfficialFirstName: | JANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5105354000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Dental | 291U00000X | 05D1018270 | CA | N |   | Laboratories | Clinical Medical Laboratory |   | 261QF0400X | 140000675 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | FHC71034F | 05 | CA |   | MEDICAID | HAP71034F | 01 | CA | FPACT | OTHER |