1336324904 NPI number — LA MAESTRA FAMILY CLINIC

Table of content: JESSICA MARIE PELFREY LMT (NPI 1316277320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336324904 NPI number — LA MAESTRA FAMILY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA MAESTRA FAMILY CLINIC
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:
1336324904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2010
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:
92105-1609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-280-1105
Provider Business Mailing Address Fax Number:
619-285-8134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 N HIGHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NATIONAL CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91950-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-434-7308
Provider Business Practice Location Address Fax Number:
619-434-7310
Provider Enumeration Date:
01/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MARSELIAN
Authorized Official First Name:
ZARA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
619-584-1612

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  550000157 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: BCP71142F . This is a "CDP CANCER DETECTION PROG" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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