Healthcare Provider Details

I. General information

NPI: 1619289782
Provider Name (Legal Business Name): CLINICA LATINA, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 07/06/2010
Certification Date:
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

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

V. Phone/Fax

Practice location:
  • Phone: 414-645-6665
  • 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 Code302R00000X
TaxonomyHealth Maintenance Organization
License Number19077
License Number StateWI

VIII. Authorized Official

Name: DANDRE LASHAWN TURNER
Title or Position: OFFICE MANAGER
Credential:
Phone: 414-645-6665