1912301110 NPI number — LA MAESTRA FAMILY CLINIC, INC.

Table of content: (NPI 1912301110)

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: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • 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" .

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





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