MEDICARE: LA MAESTRA FAMILY CLINIC

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	261QF0400X	Federally Qualified Health Center (FQHC)		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	EAP00011F	OTHER	CA	EAPC PROVIDER NUMBER
2	BCP70472G	OTHER	CA	CDP PROVIDER NUMBER
3	HAP70472G	OTHER	CA	FAMILY PACT PROVIDER NUMB

General Provider Information

NPI Number	:	1336353721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA MAESTRA FAMILY CLINIC

Provider Business Mailing Address
First Line	:	4060 FAIRMOUNT AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1609
Country	:	US
Telephone Number	:	619-280-1105
Fax Number	:	619-284-4731

Provider Business Practice Location Address
First Line	:	4060 FAIRMOUNT AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1609
Country	:	US
Telephone Number	:	619-280-1105
Fax Number	:	619-284-4731

Authorized Official
Title or Position	:	CEO
Name	:	MS. ZARA MARSELIAN
Credential	:
Telephone Number	:	619-584-1612

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	09/16/2010

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Directions to “LA MAESTRA FAMILY CLINIC ” Practice Location

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