Provider Demographics
NPI:1952027609
Name:LA CLINICA DE LOS CAMPESINOS, INC
Entity Type:Organization
Organization Name:LA CLINICA DE LOS CAMPESINOS, INC
Other - Org Name:FAMILY HEALTH LA CLINICA WAUTOMA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT AND CONTRACTING 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 1:400 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-6922
Practice Address - Country:US
Practice Address - Phone:920-787-5514
Practice Address - Fax:920-787-4737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CLINICA DE LOS CAMPESINOS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32955200Medicaid