Basic Information
| Provider Information | |||||||||
| NPI: | 1053312587 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST VALLEY HEALTH CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MACLAY WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1172 N MACLAY AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913401328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188981388 | ||||||||
| FaxNumber: | 8183654031 | ||||||||
| Practice Location | |||||||||
| Address1: | 12451 W. GAIN STREET | ||||||||
| Address2: | |||||||||
| City: | PACOIMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188972193 | ||||||||
| FaxNumber: | 8188902394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WYARD | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8188981388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.