Basic Information
| Provider Information | |||||||||
| NPI: | 1073177739 | ||||||||
| 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: | 6195841612 | ||||||||
| FaxNumber: | 6192816738 | ||||||||
| Practice Location | |||||||||
| Address1: | 4060 FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195841612 | ||||||||
| FaxNumber: | 6192816738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | VU | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 6192691292 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | FHC70472G | 05 | CA | MEDICAID |