Provider Demographics
NPI:1184613234
Name:CLINICA CAMPESINA FAMILY HEALTH SERVICES
Entity type:Organization
Organization Name:CLINICA CAMPESINA FAMILY HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-926-0625
Mailing Address - Street 1:1735 S PUBLIC RD
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:
Mailing Address - Fax:
Practice Address - Street 1:2525 13TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4104
Practice Address - Country:US
Practice Address - Phone:720-565-4270
Practice Address - Fax:303-417-2846
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLINICA CAMPESINA FAMILY HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-20
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO180376261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60689358Medicaid
CO061836Medicare PIN
COE1708Medicare UPIN