Basic Information
| Provider Information | |||||||||
| NPI: | 1912301110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA MAESTRA FAMILY CLINIC, INC. | ||||||||
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| OtherOrganizationName: | LA MAESTRA SELDOVIA CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 259 SELDOVIA STREET, | ||||||||
| Address2: | BOX 206 | ||||||||
| City: | SELDOVIA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996630206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072347825 | ||||||||
| FaxNumber: | 9072347825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2014 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | VU | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR 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 | 363A00000X | 1011073 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | 1011073 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.