Healthcare Provider Details

I. General information

NPI: 1003433830
Provider Name (Legal Business Name): LA CLINICA LATINA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2020
Last Update Date: 06/27/2020
Certification Date: 06/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1238 S CESAR E CHAVEZ DR
MILWAUKEE WI
53204-2267
US

IV. Provider business mailing address

PO BOX 639
THIENSVILLE WI
53092-0639
US

V. Phone/Fax

Practice location:
  • Phone: 414-645-6666
  • Fax: 414-645-6732
Mailing address:
  • Phone: 414-645-6665
  • Fax: 414-645-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NEDAL MEJALLI
Title or Position: REGISTERED AGENT
Credential: MD
Phone: 414-645-6665