Basic Information
| Provider Information | |||||||||
| NPI: | 1063143568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA MAESTRA FAMILY CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4060 FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6199724165 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4305 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6199724165 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2022 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | VU | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6199724165 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 343900000X | Y | Transportation Services | Non-emergency Medical Transport (VAN) |
No ID Information.