Basic Information
Provider Information | |||||||||
NPI: | 1831569680 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LA CLINICA DE LA RAZA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | POBOX 2210 | ||||||||
Address2: |   | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 94623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5105352965 | ||||||||
FaxNumber: | 5105354128 | ||||||||
Practice Location | |||||||||
Address1: | 3451 E 12TH ST | ||||||||
Address2: |   | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946013463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5105352965 | ||||||||
FaxNumber: | 5105354128 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2015 | ||||||||
LastUpdateDate: | 10/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GERONIMO | ||||||||
AuthorizedOfficialFirstName: | BELKYS | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | NUTRITIONIST LL | ||||||||
AuthorizedOfficialTelephone: | 5105352965 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | 642175 | IL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.