NPIMap

Organization Active NPI

La Clinica de Los Campesinos, Inc

  • Pharmacy
  • Wautoma, WI
National Provider Identifier
1174322846
Registry record updated Jun 17, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
Legal business name
LA CLINICA DE LOS CAMPESINOS, INC
Practice address
400 S Townline Rd
Wautoma, WI 54982-6922
Phone
(920) 647-8984
Fax
(920) 647-8991
NPI assigned
Mar 13, 2025
Last updated
Jun 17, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 17, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kellen DorffNPI 1902439748
Title
Director of Pharmacy
Phone
(920) 647-8984

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X Primary

Addresses

Primary practice location

400 S Townline Rd
Wautoma, WI 54982-6922

Mailing address

400 S Townline Rd
Wautoma, WI 54982-6922
Phone (920) 647-8984

Other names 1

  • Noble Community Clinics RDS Wautoma Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20250521003177 WI Part B Supplier - Pharmacy 8729996574 Practice locations: Wautoma, WI

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
La Clinica de Los Campesinos Inc3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

2501 Main St
Stevens Point, WI 54481
Phone (715) 254-9072

400 S Townline Rd
Wautoma, WI 54982
Phone (920) 647-8984

400 S Townline Rd
#1440
Wautoma, WI 54982
Phone (920) 787-5514

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Noble Community ClinicsWautoma, WI, CCN 521823 Federally qualified health center Operational/Managerial Control Dec 21, 2016

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 44

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 44

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1741824000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1750118400000",
    "number": "1174322846",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 S TOWNLINE RD",
            "city": "WAUTOMA",
            "state": "WI",
            "postal_code": "549826922",
            "telephone_number": "920-647-8984",
            "fax_number": "920-647-8991"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 S TOWNLINE RD",
            "city": "WAUTOMA",
            "state": "WI",
            "postal_code": "549826922",
            "telephone_number": "920-647-8984",
            "fax_number": "920-647-8991"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LA CLINICA DE LOS CAMPESINOS, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-03-13",
        "last_updated": "2025-06-17",
        "certification_date": "2025-06-17",
        "status": "A",
        "authorized_official_last_name": "DORFF",
        "authorized_official_first_name": "KELLEN",
        "authorized_official_title_or_position": "DIRECTOR OF PHARMACY",
        "authorized_official_telephone_number": "920-647-8984"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Noble Community Clinics RDS Wautoma",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Wautoma, WI

Sources for this page

Verify at the official NPI Registry.