Basic Information
| Provider Information | |||||||||
| NPI: | 1306929443 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LA MAESTRA FAMILY CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA MAESTRA COMMUNITY HEALTH CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4060 FAIRMOUNT AVENUE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192801105 | ||||||||
| FaxNumber: | 6192816738 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 SOUTH FIRST STREET | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193120347 | ||||||||
| FaxNumber: | 6197495480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARSELIAN | ||||||||
| AuthorizedOfficialFirstName: | ZARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6195841612 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | BCP71086F | 01 | CA | CDP PROVIDER NUMBER | OTHER | FHC71086F | 05 | CA | MEDICAID | EAP00011F | 01 | CA | EAPC PROVIDER NUMBER | OTHER | HAP71086F | 01 | CA | SOFP PROVIDER NUMBER | OTHER |