Basic Information
| Provider Information | |||||||||
| NPI: | 1356528376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST VALLEY HEALTH CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1172 N. MACLAY AVE. | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188981388 | ||||||||
| FaxNumber: | 8183654031 | ||||||||
| Practice Location | |||||||||
| Address1: | 12756 VAN NUYS BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | PACOIMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188960531 | ||||||||
| FaxNumber: | 8188965850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | WYARD | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8188981388 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QF0050X | 960000189 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical |
ID Information
| ID | Type | State | Issuer | Description | HAP11838F | 01 | CA | FAMILY PACT | OTHER |