Provider Demographics
NPI:1467718791
Name:LA MAESTRA FAMILY CLINIC, INC.
Entity Type:Organization
Organization Name:LA MAESTRA FAMILY CLINIC, INC.
Other - Org Name:LA MAESTRA COMMUNITY HEALTH CENTERS - MOBILE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ZARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSELIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-584-1612
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?:Yes
Parent Organization LBN:LA MAESTRA FAMILY CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)