Healthcare Provider Details

I. General information

NPI: 1235130600
Provider Name (Legal Business Name): NORTHEAST VALLEY HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SAN FERNANDO RD
SAN FERNANDO CA
91340-3115
US

IV. Provider business mailing address

1172 N MACLAY AVE
SAN FERNANDO CA
91340-1328
US

V. Phone/Fax

Practice location:
  • Phone: 818-365-8086
  • Fax: 818-898-4826
Mailing address:
  • Phone: 818-898-1388
  • Fax: 818-365-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

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