Provider Demographics
NPI:1073177739
Name:LA MAESTRA FAMILY CLINIC, INC.
Entity type:Organization
Organization Name:LA MAESTRA FAMILY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF CORPORATE COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-269-1292
Mailing Address - Street 1:4060 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1608
Mailing Address - Country:US
Mailing Address - Phone:619-584-1612
Mailing Address - Fax:619-281-6738
Practice Address - Street 1:4060 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1608
Practice Address - Country:US
Practice Address - Phone:619-584-1612
Practice Address - Fax:619-281-6738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70472GMedicaid