Basic Information
| Provider Information | |||||||||
| NPI: | 1659490308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA MAESTRA FAMILY CLINIC INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4185 FAIRMOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195841612 | ||||||||
| FaxNumber: | 6195782589 | ||||||||
| Practice Location | |||||||||
| Address1: | 4305 UNIVERSITY AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921051645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195011235 | ||||||||
| FaxNumber: | 6195013171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | AREIZAGA | ||||||||
| AuthorizedOfficialFirstName: | ALEJANDRINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 6195077756 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | FHC71118F | 05 | CA | MEDICAID |