NPIMap

Organization Active NPI

La Maestra Family Clinic, Inc.

Doing business as La Maestra Community Health Centers

  • Federally Qualified Health Center (FQHC)
  • San Diego, CA
National Provider Identifier
1609849074
Registry record updated Dec 7, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LA MAESTRA FAMILY CLINIC, INC.
Doing business as
La Maestra Community Health Centers
Practice address
4060 Fairmount Ave
San Diego, CA 92105-1608
Phone
(619) 280-4213
Fax
(619) 281-6738
NPI assigned
Feb 8, 2006
Last updated
Dec 7, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 7, 2021

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

Authorized official

Name
Zara Marselian
Title
Ceo
Phone
(619) 961-0818

Specialties & licenses 1

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

Addresses

Primary practice location

4060 Fairmount Ave
San Diego, CA 92105-1608

Mailing address

4060 Fairmount Ave
San Diego, CA 92105-1608
Phone (619) 961-0818

Other identifiers 1

IdentifierTypeStateIssuer
FHC70472GMedicaidCA

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
O20070206000747 CA Part A Provider - Federally Qualified Health Center (FQHC) 7113968512 Practice locations: San Diego, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609849074. Details of each certification follow.

Federally qualified health center certification: CCN 051076

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
Apr 6, 2007
Last certification
Apr 6, 2007
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1991 in CA
Enrollment address
4060 Fairmount Ave
San Diego, CA 92105-1608

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

Locations

1032 Broadway
El Cajon, CA 92021
Phone 6192804213 ext. 3176

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 Director Jan 1, 2018
Graciela Putzoli Individual Corporate Director Jan 30, 2007
Mark Boyer Individual Corporate Director Jan 1, 2017
Louie Cazares Individual Corporate Director Jan 1, 2019
Peter Both Gach Individual Corporate Director Jan 1, 2022
Tom Vu Individual Corporate DirectorChief of Corporate Compliance May 6, 2011
W-2 Managing EmployeeChief of Corporate Compliance May 6, 2011
Zara Marselian Individual Corporate Director Jan 30, 2007
W-2 Managing Employee Nov 21, 2011
Operational/Managerial ControlChief Executive Officer Jan 30, 2007
Samuel Mireles Individual Corporate Director Jan 30, 2007
Charlene Castro Individual Corporate Director Jan 30, 2007
Monica de la Torre Individual Corporate Director Jan 1, 2013
Yessica Quiroz Individual Corporate Director Jan 30, 2007
Christopher Ewald Individual Corporate Director Jan 1, 2014
Robert Marquez Individual Corporate Director Jan 1, 2019

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1139356800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1638835200000",
    "number": "1609849074",
    "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": "619-961-0818",
            "fax_number": "619-281-6738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4060 FAIRMOUNT AVE",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921051608",
            "telephone_number": "619-280-4213",
            "fax_number": "619-281-6738"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LA MAESTRA FAMILY CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-02-08",
        "last_updated": "2021-12-07",
        "certification_date": "2021-12-07",
        "status": "A",
        "authorized_official_last_name": "MARSELIAN",
        "authorized_official_first_name": "ZARA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "619-961-0818"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC70472G",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "La Maestra Community Health Centers",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "La Maestra Community Health Centers",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Diego, CA

Sources for this page

Verify at the official NPI Registry.