NPIMap

Organization Active NPI

La Clinica de la Raza Inc

  • Federally Qualified Health Center (FQHC)
  • Vallejo, CA
National Provider Identifier
1992811392
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
Practice address
243 Georgia St
Suite B
Vallejo, CA 94590-5905
Phone
(707) 556-8100
Fax
(707) 556-8107
NPI assigned
Aug 21, 2006
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) 354-4000

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 110000270 CA Primary
Clinical Medical Laboratory 291U00000X 05D0880562 CA

Addresses

Primary practice location

243 Georgia St
Suite B
Vallejo, CA 94590-5905

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
FHC70543GMedicaidCA

Other names 1

  • La Clinica 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
O20070905000623 CA Part A Provider - Federally Qualified Health Center (FQHC) 1557258282 Practice locations: Vallejo, CA

Federally qualified health center certification: CCN 551915

Legal name
LA CLINICA DE LA RAZA INC
Doing business as
LA CLINICA VALLEJO
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 6, 2002
Last certification
Nov 6, 2002
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Feb 23, 1971 in CA
Enrollment address
415 Georgia St
Vallejo, CA 94590-6004

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0880562La Clinica Vallejo Medical415 Georgia St, Vallejo, CA 94590Provider-performed microscopyDec 15, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 15

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 Director Aug 29, 2007
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 Aug 29, 2007
Jane Garcia Individual Corporate OfficerChief Executive Officer Aug 29, 2007
W-2 Managing EmployeeChief Executive Officer Aug 29, 2007
Elizabeth Diaz Individual Corporate DirectorBoard Member Jul 17, 2017
Ramon J Terrazas Individual Corporate DirectorBoard Member Aug 29, 2007
Rodney Leggett Individual Corporate DirectorBoard Member Sep 17, 2012
Maria Tsaklanos Individual Corporate DirectorBoard Member Jul 17, 2017
Robert Katter Individual Corporate OfficerImmediate Past President Jul 1, 2013
Corporate DirectorBoard Member Aug 29, 2007
Norma Guerrero Individual Corporate Director Aug 29, 2007
Andrew Cleophas Peterson Individual Corporate DirectorBoard Member Oct 1, 2013
Paul M Swenson Individual Corporate DirectorBoard Member Jul 9, 2008
Dora Eckenfelder Individual Corporate DirectorBoard Member Jul 17, 2017

Practitioners & affiliated clinicians

Practitioners 147

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 147

NPI Registry JSON

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

{
    "created_epoch": "1156118400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1571270400000",
    "number": "1992811392",
    "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": "243 GEORGIA ST",
            "address_2": "SUITE B",
            "city": "VALLEJO",
            "state": "CA",
            "postal_code": "945905905",
            "telephone_number": "707-556-8100",
            "fax_number": "707-556-8107"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LA CLINICA DE LA RAZA INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-21",
        "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": "510-354-4000",
        "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": "05D0880562",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC70543G",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "La Clinica Vallejo",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "La Clinica Vallejo",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Vallejo, CA

Sources for this page

Verify at the official NPI Registry.