Basic Information
| Provider Information | |||||||||
| NPI: | 1437478351 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA MAESTRA FAMILY CLINIC, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA MAESTRA COMMUNITY HEALTH CENTERS-LEMON GROVE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7967 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LEMON GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919451809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197417423 | ||||||||
| FaxNumber: | 6197132589 | ||||||||
| Practice Location | |||||||||
| Address1: | 4185 FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192801105 | ||||||||
| FaxNumber: | 6192858134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2010 | ||||||||
| LastUpdateDate: | 05/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | MARSELIAN | ||||||||
| AuthorizedOfficialFirstName: | ZARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6195841612 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.