Basic Information
| Provider Information | |||||||||
| NPI: | 1326578774 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LA MAESTRA FAMILY CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA MAESTRA COMMUNITY PHARMACY EL CAJON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4060 FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051608 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 165 S 1ST ST STE 1B | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920194795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195841612 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2017 | ||||||||
| LastUpdateDate: | 06/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | VU | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 6199724165 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 55271 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | FHC70472G | 05 | CA | MEDICAID |