Provider Demographics
NPI:1912301110
Name:LA MAESTRA FAMILY CLINIC, INC.
Entity Type:Organization
Organization Name:LA MAESTRA FAMILY CLINIC, INC.
Other - Org Name:LA MAESTRA SELDOVIA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR 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 1:259 SELDOVIA STREET,
Practice Address - Street 2:BOX 206
Practice Address - City:SELDOVIA
Practice Address - State:AK
Practice Address - Zip Code:99663-0206
Practice Address - Country:US
Practice Address - Phone:907-234-7825
Practice Address - Fax:907-234-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-16
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
AK1011073363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty