Basic Information
Provider Information
NPI: 1124276324
EntityType: 2
ReplacementNPI:  
OrganizationName: LACLINICA DE LOS CAMPESINOS, INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: FAMILY HEALTH/LA CLINICA
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1440
Address2: 400 S TOWNLINE RD
City: WAUTOMA
State: WI
PostalCode: 549821440
CountryCode: US
TelephoneNumber: 9207875514
FaxNumber: 9207874737
Practice Location
Address1: 400 S TOWNLINE RD
Address2:  
City: WAUTOMA
State: WI
PostalCode: 549821440
CountryCode: US
TelephoneNumber: 9207875514
FaxNumber: 9207874737
Other Information
ProviderEnumerationDate: 09/03/2008
LastUpdateDate: 04/08/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WALDVOGEL
AuthorizedOfficialFirstName: LAURA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: PRESIDENT/CEO
AuthorizedOfficialTelephone: 9207875514
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 04/08/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X  N193200000X MULTI-SPECIALTY GROUPDental ProvidersDentist 
207Q00000X WIY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
7003001WIMEDICAREOTHER
3295520005WI MEDICAID


Home