Healthcare Provider Details

I. General information

NPI: 1184613234
Provider Name (Legal Business Name): CLINICA CAMPESINA FAMILY HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 13TH ST
BOULDER CO
80304-4104
US

IV. Provider business mailing address

1735 S PUBLIC RD
LAFAYETTE CO
80026-7093
US

V. Phone/Fax

Practice location:
  • Phone: 720-565-4270
  • Fax: 303-417-2846
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number180376
License Number StateCO

VIII. Authorized Official

Name: BRIAN J JOHNSTON
Title or Position: CFO
Credential:
Phone: 303-926-0625