52D0398011 CLIA NUMBER - LA CLINICA DE LOS CAMPESINOS INC, DBA FAMILY HEALTH LA CLINICA

Laboratory Demographics

CLIA Number: 52D0398011

Facility Name: LA CLINICA DE LOS CAMPESINOS INC, DBA FAMILY HEALTH LA CLINICA

Facility Address:
400 S TOWNLINE RD
WAUTOMA, WI
ZIP 54982
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Facility Phone Number: 920 787-5514

Facility Type: Federally Qualified Health Center

Certificate Type: Waiver

NPI Number: 1790786929

Taxonomy: 261QF0400X - Clinic/Center

CLIA Record

Field Name	Field Value
CLIA Number	52D0398011
LAB Type	Federally Qualified Health Center
Facility Name	LA CLINICA DE LOS CAMPESINOS INC, DBA FAMILY HEALTH LA CLINICA
Street	400 S TOWNLINE RD
City	WAUTOMA
State	WI
ZIP	54982
Phone	920 787-5514
CertificateType	4
CertificateEffectiveDate	12/14/2023
CertificateExpirationDate	12/13/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024