Provider Demographics
NPI:1871663559
Name:LA CLINICA LATINO COMMUNITY HEALTH CENTERS
Entity Type:Organization
Organization Name:LA CLINICA LATINO COMMUNITY HEALTH CENTERS
Other - Org Name:LA CLINICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MED
Authorized Official - Phone:314-664-5565
Mailing Address - Street 1:3646 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4747
Mailing Address - Country:US
Mailing Address - Phone:314-664-5565
Mailing Address - Fax:314-773-0709
Practice Address - Street 1:3646 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4747
Practice Address - Country:US
Practice Address - Phone:314-664-5565
Practice Address - Fax:314-773-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1H15251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable