Basic Information
Provider Information | |||||||||
NPI: | 1629379896 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LA CLINICA DE LA RAZA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CASA DEL SOL III | ||||||||
OtherOrganizationType: | 5 | ||||||||
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: | 1415-1423 FRUITVALE AVE | ||||||||
Address2: |   | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946012320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5105358400 | ||||||||
FaxNumber: | 5105358460 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/04/2010 | ||||||||
LastUpdateDate: | 03/01/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARCIA | ||||||||
AuthorizedOfficialFirstName: | JANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5105354000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LA CLINICA DE LA RAZA, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   | CA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QF0400X |   | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 0191 | 01 | CA | AC BHCS | OTHER |