Healthcare Provider Details

I. General information

NPI: 1093534463
Provider Name (Legal Business Name): LA MAESTRA FAMILY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 E MAIN ST
EL CAJON CA
92021-7290
US

IV. Provider business mailing address

4060 FAIRMOUNT AVE
SAN DIEGO CA
92105-1608
US

V. Phone/Fax

Practice location:
  • Phone: 619-584-1612
  • Fax: 619-281-6738
Mailing address:
  • Phone: 619-972-4165
  • Fax: 619-281-6738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TOM VU
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 619-972-4165