Healthcare Provider Details

I. General information

NPI: 1356528376
Provider Name (Legal Business Name): NORTHEAST VALLEY HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12756 VAN NUYS BOULEVARD
PACOIMA CA
91331
US

IV. Provider business mailing address

1172 N. MACLAY AVE.
SAN FERNANDO CA
91340
US

V. Phone/Fax

Practice location:
  • Phone: 818-896-0531
  • Fax: 818-896-5850
Mailing address:
  • Phone: 818-898-1388
  • Fax: 818-365-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number960000189
License Number StateCA

VIII. Authorized Official

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