MEDICARE: NORTHWEST VALLEY FAMILY MEDICAL CLINIC, INC.

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	207Q00000X	Family Medicine Physician	A70428	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255426383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST VALLEY FAMILY MEDICAL CLINIC, INC.

Provider Business Mailing Address
First Line	:	19182 DUNURE PLACE
Second Line	:
City	:	NORTHRIDGE
State	:	CA
Zip	:	91326
Country	:	US
Telephone Number	:	818-368-2859
Fax Number	:	661-259-8295

Provider Business Practice Location Address
First Line	:	17909 SOLEDAD CANYON RD # 100
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91387-3210
Country	:	US
Telephone Number	:	661-367-3500
Fax Number	:

Authorized Official
Title or Position	:	VICE-PRESIDENT
Name	:	DR. MARTINA BARTE MASONGSONG
Credential	:	M.D.
Telephone Number	:	818-388-1951

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	12/19/2022

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