Provider Demographics
NPI:1790786929
Name:LA CLINICA DE LOS CAMPESINOS, INC
Entity Type:Organization
Organization Name:LA CLINICA DE LOS CAMPESINOS, INC
Other - Org Name:MAUSTON DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT AND CREDENTIALING SPEC.
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-787-9459
Mailing Address - Street 1:PO BOX 1440
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-1440
Mailing Address - Country:US
Mailing Address - Phone:920-787-5514
Mailing Address - Fax:920-787-4737
Practice Address - Street 1:3125 MAIN ST
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-3269
Practice Address - Country:US
Practice Address - Phone:920-787-5514
Practice Address - Fax:920-787-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122300000X, 207Q00000X
207Q00000X, 261QF0400X, 261QM0801X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100076513Medicaid
WI100080272Medicaid
WI32955200Medicaid
WI100076692Medicaid