Provider Demographics
NPI:1174322846
Name:LA CLINICA DE LOS CAMPESINOS, INC
Entity type:Organization
Organization Name:LA CLINICA DE LOS CAMPESINOS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:KELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DORFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-647-8984
Mailing Address - Street 1:400 S TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-6922
Mailing Address - Country:US
Mailing Address - Phone:920-647-8984
Mailing Address - Fax:920-647-8991
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:920-647-8984
Practice Address - Fax:920-647-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy