Provider Demographics
NPI:1114928595
Name:NORTHEAST VALLEY HEALTH CORPORATION
Entity Type:Organization
Organization Name:NORTHEAST VALLEY HEALTH CORPORATION
Other - Org Name:PACOIMA HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WYARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-898-1388
Mailing Address - Street 1:1172 N MACLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-1328
Mailing Address - Country:US
Mailing Address - Phone:818-898-1388
Mailing Address - Fax:818-365-4031
Practice Address - Street 1:12756 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1626
Practice Address - Country:US
Practice Address - Phone:818-896-0531
Practice Address - Fax:818-896-5850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 261QF0400X
CA9600189261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
W14819AOtherMIN
CA051899Medicare Oscar/Certification