NPIMap

Organization Active NPI

La Maestra Family Clinic Inc

  • Federally Qualified Health Center (FQHC)
  • El Cajon, CA
National Provider Identifier
1134590086
Registry record updated Oct 16, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
090000378 Issued in CA
Legal business name
LA MAESTRA FAMILY CLINIC INC
Practice address
1032 Broadway
El Cajon, CA 92021-7416
Phone
(619) 584-1612
NPI assigned
Oct 16, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 16, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Tom Vu
Title
Director of Risk and Compliance
Phone
(619) 269-1292

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 090000378 CA Primary

Addresses

Primary practice location

1032 Broadway
El Cajon, CA 92021-7416

Mailing address

4060 Fairmount Ave
San Diego, CA 92105-1608
Phone (619) 584-1612

Other identifiers 1

IdentifierTypeStateIssuer
CMCSUB5E3MedicaidCA

Other names 1

  • La Maestra Community Health Centers Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050516000901 CA Part B Supplier - Clinic/Group Practice 7113968512 Receives reassigned benefits from 118 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: National City, CA; San Diego, CA; Lemon Grove, CA; El Cajon, CA
O20161010000296 CA Part A Provider - Federally Qualified Health Center (FQHC) 7113968512 Practice locations: El Cajon, CA

Federally qualified health center certification: CCN 751884

Legal name
LA MAESTRA FAMILY CLINIC, INC.
Doing business as
LA MAESTRA COMMUNITY HEALTH CENTERS
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 8, 2016
Last certification
Sep 8, 2016
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Jul 22, 1991 in CA
Enrollment address
1032 Broadway
El Cajon, CA 92021-7416

Other NPIs with the same Medicare PAC ID 9

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Pida Kongphouthone Individual Corporate DirectorBoard Member Jan 1, 2018
Graciela Putzoli Individual Corporate DirectorBoard Member Jun 1, 2012
Mark Boyer Individual Corporate DirectorBoard Member Jan 1, 2017
Louie Cazares Individual Corporate DirectorBoard Member Jan 1, 2019
Peter Both Gach Individual Corporate DirectorBoard Member Jan 1, 2022
Tom Vu Individual Corporate Director May 6, 2011
W-2 Managing Employee May 6, 2011
Zara Marselian Individual Corporate OfficerPresident/Ceo Aug 8, 2016
W-2 Managing EmployeePresident/Ceo May 5, 1990
Operational/Managerial ControlPresident/Ceo May 5, 1990
Samuel Mireles Individual Corporate DirectorBoard Member Apr 4, 2010
Charlene Castro Individual Corporate DirectorBoard Member Jun 1, 2012
Monica de la Torre Individual Corporate DirectorBoard Member Mar 1, 2013
Yessica Quiroz Individual Corporate DirectorBoard Member Jun 1, 2012
Christopher Ewald Individual Corporate DirectorBoard Member Jan 3, 2014
Robert Marquez Individual Corporate DirectorBoard Member Jan 1, 2019

Practitioners & affiliated clinicians

Practitioners 30

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 30

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1444953600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1444953600000",
    "number": "1134590086",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4060 FAIRMOUNT AVE",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921051608",
            "telephone_number": "619-584-1612",
            "fax_number": "619-281-6738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1032 BROADWAY",
            "city": "EL CAJON",
            "state": "CA",
            "postal_code": "920217416",
            "telephone_number": "619-584-1612"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LA MAESTRA FAMILY CLINIC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-16",
        "last_updated": "2015-10-16",
        "status": "A",
        "authorized_official_last_name": "VU",
        "authorized_official_first_name": "TOM",
        "authorized_official_title_or_position": "DIRECTOR OF RISK AND COMPLIANCE",
        "authorized_official_telephone_number": "619-269-1292",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "090000378",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "CMCSUB5E3",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "La Maestra Community Health Centers",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in El Cajon, CA

Sources for this page

Verify at the official NPI Registry.