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	261QD0000X	Dental Clinic/Center
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1548960834
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST VALLEY HEALTH CORPORATION

Provider Business Mailing Address
First Line	:	1172 N MACLAY AVE OFC
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	:	17909 SOLEDAD CANYON RD FL 2
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91387-3210
Country	:	US
Telephone Number	:	661-673-8888
Fax Number	:	661-298-8668

Authorized Official
Title or Position	:	CEO
Name	:	MS. KIMBERLY WYARD
Credential	:
Telephone Number	:	818-898-1388

Provider Enumeration Date	:	03/06/2023
Last Update Date	:	03/06/2023

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