Basic Information
| Provider Information | |||||||||
| NPI: | 1831186915 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINICA CAMPESINA FAMILY HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLINICA CAMPESINA - LAFAYETTE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 S PUBLIC RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800267093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036653036 | ||||||||
| FaxNumber: | 3036659566 | ||||||||
| Practice Location | |||||||||
| Address1: | 1735 S PUBLIC RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800267093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036659310 | ||||||||
| FaxNumber: | 3039260363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | SIMON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3036653036 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 0556 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 05638259 | 05 | CO | MEDICAID |