NPIMap

Organization Active NPI

Clinica Campesina Family Health Services

Doing business as Clinica Family Health

  • Federally Qualified Health Center (FQHC)
  • Black Hawk, CO
National Provider Identifier
1780337063
Registry record updated Jan 27, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CLINICA CAMPESINA FAMILY HEALTH SERVICES
Doing business as
Clinica Family Health
Practice address
972 Golden Gate Canyon Rd
Black Hawk, CO 80422-8993
Phone
(303) 650-4460
NPI assigned
Jan 27, 2022
Last updated
Jan 27, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
CLINICA CAMPESINA FAMILY HEALTH SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 27, 2022

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

Authorized official

Name
Mr. Brian J Johnston
Title
Cfo
Phone
(303) 926-0625

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

972 Golden Gate Canyon Rd
Black Hawk, CO 80422-8993

Mailing address

1735 S Public Rd
Lafayette, CO 80026-7093
Phone (303) 926-0625

Other names 1

  • Clinica Family Health Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220811001174 CO Part A Provider - Federally Qualified Health Center (FQHC) 7315850484 Practice locations: Black Hawk, CO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780337063. Details of each certification follow.

Federally qualified health center certification: CCN 061034

Legal name
CLINICA CAMPESINA FAMILY HEALTH SERVICES
Doing business as
CLINICA FAMILY HEALTH SERVICES
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 12, 2022
Last certification
Jul 12, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Mar 22, 2022 in CO
Enrollment address
972 Golden Gate Canyon Rd
Black Hawk, CO 80422-8993

Other NPIs with the same Medicare PAC ID 8

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
06D2264311Clinica Family Health - Gilpin County972 Golden Gate Canyon Road, Suite 300, Black Hawk, CO 80422Provider-performed microscopyJul 11, 2028

National Provider Directory

National Provider Directory
Tax ID family
Clinica Campesina Fam H27 organizations share this tax ID, including this one
Part of
Clinica Campesina Fam H

Other organizations with this tax ID 26

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

View all 26

Locations

972 Golden Gate Canyon Rd
Black Hawk, CO 80422
Phone (303) 582-5086

Ownership & related parties

All disclosed owners & managing parties 15

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Inez D Buggs Individual Corporate OfficerBoard Member Oct 1, 2009
Jeff Zayach Individual Corporate OfficerBoard Member Aug 1, 2021
Carolina Flores Manross Individual Corporate OfficerBoard Member Aug 1, 2020
Douglas Jones Individual Corporate OfficerBoard Member Sep 1, 2011
Ella Padilla Individual Corporate OfficerBoard Member Sep 1, 2018
Matthew Antush Individual Corporate OfficerBoard Member Jul 1, 2019
Heather Elkins Individual Corporate OfficerBoard Member Apr 1, 2017
Brian Johnston Individual Corporate OfficerCfo Nov 29, 2022
Corporate DirectorCfo Nov 29, 2022
W-2 Managing EmployeeCfo Nov 29, 2022
Cherlyn a Marriott Individual Corporate OfficerBoard Member Sep 1, 2011
Lizandro Gonzalez Individual Corporate OfficerBoard Member Aug 1, 2020
Clinica Campesina Family Health Services Organization, Black Hawk, CO Non-profit Other Jun 1, 2022
Edson Hernandez Individual Corporate OfficerBoard Member Oct 1, 2017
Mayra Martinez Individual Corporate OfficerBoard Member Aug 1, 2016
Heidy Ordonez Individual Corporate OfficerBoard Member Sep 1, 2017
Simon G Smith Individual Contracted Managing EmployeeCeo Jan 10, 2011
Corporate OfficerCeo Jan 10, 2011
Corporate DirectorCeo Jan 10, 2011
W-2 Managing EmployeeCeo Jan 10, 2011
OtherCeo Jan 11, 2011

Owners & managing parties with NPI records 8

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Clinica Family HealthNederland, CO, CCN 061033 Federally qualified health center Other Jun 1, 2022

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 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1643241600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643241600000",
    "number": "1780337063",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1735 S PUBLIC RD",
            "city": "LAFAYETTE",
            "state": "CO",
            "postal_code": "800267093",
            "telephone_number": "303-926-0625"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "972 GOLDEN GATE CANYON RD",
            "city": "BLACK HAWK",
            "state": "CO",
            "postal_code": "804228993",
            "telephone_number": "303-650-4460"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLINICA CAMPESINA FAMILY HEALTH SERVICES",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CLINICA CAMPESINA FAMILY HEALTH SERVICES",
        "enumeration_date": "2022-01-27",
        "last_updated": "2022-01-27",
        "certification_date": "2022-01-27",
        "status": "A",
        "authorized_official_last_name": "JOHNSTON",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "303-926-0625",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Clinica Family Health",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Black Hawk, CO

Sources for this page

Verify at the official NPI Registry.