MEDICARE: NORTHEAST VALLEY HEALTH CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	261QF0400X	Federally Qualified Health Center (FQHC)

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	05-1086	OTHER	CA	MEDICARE PART A
4	CB204579	OTHER	CA	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	FHC70582F	OTHER	CA	MEDI-CAL
2	W14819D	OTHER		MIN

General Provider Information

NPI Number	:	1184625568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST VALLEY HEALTH CORPORATION

Provider Business Mailing Address
First Line	:	1172 N MACLAY AVE
Second Line	:
City	:	SAN FERNANDO
State	:	CA
Zip	:	91340-1328
Country	:	US
Telephone Number	:	818-898-1388
Fax Number	:	818-270-9585

Provider Business Practice Location Address
First Line	:	6551 VAN NUYS BLVD FL 2
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-1566
Country	:	US
Telephone Number	:	818-765-8656
Fax Number	:	818-765-6982

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MRS. KIMBERLY WYARD
Credential	:
Telephone Number	:	818-898-1388

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	02/22/2022

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Directions to “NORTHEAST VALLEY HEALTH CORPORATION ” Practice Location

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