Provider Demographics
NPI:1053526756
Name:LA MAESTRA FAMILY CLINIC
Entity type:Organization
Organization Name:LA MAESTRA FAMILY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ZARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSELIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-584-1612
Mailing Address - Street 1:4185 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1609
Mailing Address - Country:US
Mailing Address - Phone:619-584-1612
Mailing Address - Fax:619-281-6738
Practice Address - Street 1:101 N HIGHLAND AVE STE A
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-1435
Practice Address - Country:US
Practice Address - Phone:619-434-7308
Practice Address - Fax:619-434-7310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP71142FOtherFAMILY PACT PROVIDER #