Provider Demographics
NPI:1093702177
Name:CLINICA CAMPESINA FAMILY HEALTH SERVICES
Entity Type:Organization
Organization Name:CLINICA CAMPESINA FAMILY HEALTH SERVICES
Other - Org Name:CLINICA CAMPESINA - THORNTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-665-3036
Mailing Address - Street 1:1735 S PUBLIC RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-7093
Mailing Address - Country:US
Mailing Address - Phone:303-665-3036
Mailing Address - Fax:303-665-9566
Practice Address - Street 1:8990 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4537
Practice Address - Country:US
Practice Address - Phone:720-929-1655
Practice Address - Fax:720-929-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0556261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17001846Medicaid
CO17001846Medicaid