1528080470 NPI number — LA CLINICA DE LA RAZA INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528080470 NPI number — LA CLINICA DE LA RAZA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA CLINICA DE LA RAZA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LA CLINICA PITTSBURG DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528080470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 FRUITVALE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94601-2322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-535-4000
Provider Business Mailing Address Fax Number:
510-535-4189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
339 E LELAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PITTSBURG
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94565-4911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-431-1250
Provider Business Practice Location Address Fax Number:
925-431-1252
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
510-535-4000

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FHC70833F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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