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CH05090D LA CLINICA DE LOS CAMPESINOS, INC. (Active)
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Main Details
Name
LA CLINICA DE LOS CAMPESINOS, INC.
Subdivision Name
Noble Community Clinics - Beaver Dam Spring Street
Type
HRSA-Funded Health Center
Site ID
BPS-H80-037127
340B ID
CH05090D
Grant Number
H80CS00713
Additional Details
Current Program Status
Active
Registration Date
1/2/2024
Participating Start Date
4/1/2024
Participating Approval Date
1/8/2024
Last Recertification Date
2/13/2025
Contacts
Authorizing Official
La Clinica de los Campesinos
Laura Waldvogel, CEO
(920) 787-9406
Primary Contact
La Clinica De Los Campesinos, Inc.
Kellen J Dorff, Director of Pharmacy
(920) 647-8984
Addresses
Street Address
1701 N Spring St
Beaver Dam, WI 53916-1178
Billing Address
LA CLINICA DE LOS CAMPESINOS INC
PO Box 1440
WAUTOMA, WI 54982
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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