Healthcare Provider Details

I. General information

NPI: 1790786929
Provider Name (Legal Business Name): LA CLINICA DE LOS CAMPESINOS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 MAIN ST
STEVENS POINT WI
54481-4000
US

IV. Provider business mailing address

PO BOX 1440
WAUTOMA WI
54982-1440
US

V. Phone/Fax

Practice location:
  • Phone: 715-254-9072
  • Fax: 715-254-9106
Mailing address:
  • Phone: 920-787-5514
  • Fax: 920-787-4737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ERIN BENDER
Title or Position: ENROLLMENT AND CONTRACT SPECIALIST
Credential:
Phone: 920-787-9459