MEDICARE: LA CLINICA DE LOS CAMPESINOS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	207Q00000X	Family Medicine Physician
2	207Q00000X	Family Medicine Physician	WI
3	122300000X	Dentist	WI
4	363LF0000X	Family Nurse Practitioner
5	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
6	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790786929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA CLINICA DE LOS CAMPESINOS, INC

Provider Business Mailing Address
First Line	:	PO BOX 1440
Second Line	:
City	:	WAUTOMA
State	:	WI
Zip	:	54982-1440
Country	:	US
Telephone Number	:	920-787-5514
Fax Number	:	920-787-4737

Provider Business Practice Location Address
First Line	:	2501 MAIN ST
Second Line	:
City	:	STEVENS POINT
State	:	WI
Zip	:	54481-4000
Country	:	US
Telephone Number	:	715-254-9072
Fax Number	:	715-254-9106

Authorized Official
Title or Position	:	ENROLLMENT AND CONTRACT SPECIALIST
Name	:	ERIN BENDER
Credential	:
Telephone Number	:	920-787-9459

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	11/21/2025

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Directions to “LA CLINICA DE LOS CAMPESINOS, INC ” Practice Location

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