1912301110 NPI number — LA MAESTRA FAMILY CLINIC, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912301110 NPI number — LA MAESTRA FAMILY CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA MAESTRA FAMILY CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912301110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4060 FAIRMOUNT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92105-1608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-584-1612
Provider Business Mailing Address Fax Number:
619-281-6738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
259 SELDOVIA STREET,
Provider Second Line Business Practice Location Address:
BOX 206
Provider Business Practice Location Address City Name:
SELDOVIA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99663-0206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-234-7825
Provider Business Practice Location Address Fax Number:
907-234-7825
Provider Enumeration Date:
10/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
VU
Authorized Official First Name:
TOM
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CORPORATE COMPLIANCE
Authorized Official Telephone Number:
619-269-1292

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1011073 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 1011073 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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