NPIMap

Organization Active NPI

La Clinica de la Raza, Inc.

Doing business as La Clinica North Vallejo

  • Federally Qualified Health Center (FQHC)
  • Vallejo, CA
National Provider Identifier
1720243454
Registry record updated Oct 17, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
110000270 Issued in CA
Legal business name
LA CLINICA DE LA RAZA, INC.
Doing business as
La Clinica North Vallejo
Practice address
220 Hospital Dr
Vallejo, CA 94589-2517
Phone
(707) 641-1900
Fax
(707) 554-2294
NPI assigned
Jul 22, 2008
Last updated
Oct 17, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 17, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Jane Garcia
Title
Chief Executive Officer
Phone
(510) 535-2915

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 110000270 CA Primary
Clinical Medical Laboratory 291U00000X 05D1087668 CA

Addresses

Primary practice location

220 Hospital Dr
Vallejo, CA 94589-2517

Mailing address

PO Box 22210
Oakland, CA 94623-2210
Phone (510) 535-4000

Other identifiers 1

IdentifierTypeStateIssuer
1720243454MedicaidCA

Other names 1

  • La Clinica North Vallejo Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040227001016 CA Part B Supplier - Clinic/Group Practice 1557258282 Receives reassigned benefits from 204 practitioners
15 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Vallejo, CA; Pittsburg, CA; Oakley, CA; Oakland, CA; Concord, CA
O20081114000429 CA Part A Provider - Federally Qualified Health Center (FQHC) 1557258282 Practice locations: Vallejo, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1720243454. Details of each certification follow.

Federally qualified health center certification: CCN 051157

Legal name
LA CLINICA DE LA RAZA INC
Doing business as
LA CLINICA NORTH VALLEJO
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 10, 2009
Last certification
Feb 10, 2009
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Feb 23, 1971 in CA
Enrollment address
220 Hospital Dr
Vallejo, CA 94589-2517

Other NPIs with the same Medicare PAC ID 10

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 15

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 15

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 16

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Yvonne Hudson-Harmon Individual Corporate DirectorBoard Member Apr 19, 2004
Aisha Hampton-Bowser Individual Corporate DirectorBoard Member Dec 8, 2007
Maria Caldera Individual Corporate DirectorBoard Member Oct 1, 2013
Daniel I Ayala Individual Corporate DirectorBoard Member Dec 17, 2013
Jill Noonan Individual Corporate DirectorBoard Member Nov 18, 2002
Jane Garcia Individual Corporate OfficerChief Executive Officer (Ceo) Mar 1, 2013
W-2 Managing EmployeeCeo Nov 3, 2008
Operational/Managerial ControlCeo Nov 3, 2008
Elizabeth Diaz Individual Corporate DirectorBoard Member Jul 17, 2017
Chris Ohman Individual Corporate DirectorBoard Secretary Jan 1, 2021
Ramon J Terrazas Individual Corporate DirectorBoard Chairman and Board President Nov 25, 1997
Rodney Leggett Individual Corporate DirectorBoard Member Sep 17, 2012
Maria Tsaklanos Individual Corporate DirectorBoard Member Jul 17, 2017
Robert Katter Individual Corporate DirectorInterim Board Vice President May 16, 2005
Norma Guerrero Individual Corporate DirectorBoard Member Jan 20, 2000
Andrew Cleophas Peterson Individual Corporate DirectorBoard Member Oct 1, 2013
Paul M Swenson Individual Corporate DirectorBoard Treasurer Jul 9, 2008
Dora Eckenfelder Individual Corporate DirectorBoard Member Jul 17, 2017

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1216684800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1571270400000",
    "number": "1720243454",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 22210",
            "city": "OAKLAND",
            "state": "CA",
            "postal_code": "946232210",
            "telephone_number": "510-535-4000",
            "fax_number": "510-535-4189"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "220 HOSPITAL DR",
            "city": "VALLEJO",
            "state": "CA",
            "postal_code": "945892517",
            "telephone_number": "707-641-1900",
            "fax_number": "707-554-2294"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LA CLINICA DE LA RAZA, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-07-22",
        "last_updated": "2019-10-17",
        "status": "A",
        "authorized_official_last_name": "GARCIA",
        "authorized_official_first_name": "JANE",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "510-535-2915",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "110000270",
            "primary": true
        },
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "CA",
            "license": "05D1087668",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1720243454",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "La Clinica North Vallejo",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "La Clinica North Vallejo",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Vallejo, CA

Sources for this page

Verify at the official NPI Registry.