Provider Demographics
NPI:1518940543
Name:CLINICA LATINA, S.C.
Entity Type:Organization
Organization Name:CLINICA LATINA, S.C.
Other - Org Name:CUDAHY PHYSICIAN ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:APONTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-645-6665
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:414-423-4100
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:1238 S CESAR E CHAVEZ DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2267
Practice Address - Country:US
Practice Address - Phone:414-645-6665
Practice Address - Fax:414-645-6732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI52D0692638OtherCLIA
WI32740300Medicaid
WI32740300Medicaid