=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396690285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA CLINICA DE LOS CAMPESINOS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2026
-----------------------------------------------------
Last Update Date | 03/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2719 CALUMET AVE
-----------------------------------------------------
City | MANITOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54220-5546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-395-2980
-----------------------------------------------------
Fax | 920-783-6804
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1440
-----------------------------------------------------
City | WAUTOMA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54982-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-395-2980
-----------------------------------------------------
Fax | 920-783-6804
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENROLLMENT AND CONTRACT SPECIALIST
-----------------------------------------------------
Name | ERIN BENDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-787-9459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------