Basic Information
| Provider Information | |||||||||
| NPI: | 1669773008 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA CLINICA DE LA RAZA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CASA DEL SOL (ASCEND ELEMENTARY SCHOOL) | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22210 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946232210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105354000 | ||||||||
| FaxNumber: | 5105354189 | ||||||||
| Practice Location | |||||||||
| Address1: | 3709 E 12TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946014001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105356200 | ||||||||
| FaxNumber: | 5105354167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 11/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5105354000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | TBD | 01 | CA | ACBHCS | OTHER |