Healthcare Provider Details

I. General information

NPI: 1902467574
Provider Name (Legal Business Name): NORTHEAST VALLEY HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7843 LANKERSHIM BLVD
NORTH HOLLYWOOD CA
91605-2523
US

IV. Provider business mailing address

1172 N MACLAY AVE
SAN FERNANDO CA
91340-1328
US

V. Phone/Fax

Practice location:
  • Phone: 818-485-5555
  • Fax: 818-485-5556
Mailing address:
  • Phone: 818-898-1388
  • Fax: 818-270-9585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. KIMBERLY WYARD
Title or Position: CHIEF EXECUITVE OFFICER
Credential:
Phone: 818-898-1388