MEDICARE: LA MAESTRA FAMILY CLINIC INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740881085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA MAESTRA FAMILY CLINIC INC.

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

Provider Business Practice Location Address
First Line	:	181 REA AVE
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-3985
Country	:	US
Telephone Number	:	619-584-1612
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OF RISK MANAGEMENT
Name	:	TOM VU
Credential	:
Telephone Number	:	619-972-4165

Provider Enumeration Date	:	11/03/2020
Last Update Date	:	11/03/2020

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