Basic Information
| Provider Information | |||||||||
| NPI: | 1881104313 | ||||||||
| 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: | 913401328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188981388 | ||||||||
| FaxNumber: | 8182709585 | ||||||||
| Practice Location | |||||||||
| Address1: | 23413 LYONS AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913553028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6615937500 | ||||||||
| FaxNumber: | 6614937501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2017 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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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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| NPICertificationDate: | 03/03/2022 | ||||||||
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.