Healthcare Provider Details

I. General information

NPI: 1023855087
Provider Name (Legal Business Name): CLINICA CAMPESINA FAMILY HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ALPINE AVE
BOULDER CO
80304-3406
US

IV. Provider business mailing address

1455 DIXON AVE
LAFAYETTE CO
80026-8879
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8500
  • Fax: 720-687-2752
Mailing address:
  • Phone: 303-443-8500
  • Fax: 720-687-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

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