Provider Demographics
NPI:1346427366
Name:NORTHEAST VALLEY HEALTH CORPORATION
Entity Type:Organization
Organization Name:NORTHEAST VALLEY HEALTH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF 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
Mailing Address - Country:US
Mailing Address - Phone:818-898-1388
Mailing Address - Fax:818-365-4031
Practice Address - Street 1:1600 SAN FERNANDO ROAD
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340
Practice Address - Country:US
Practice Address - Phone:818-365-8086
Practice Address - Fax:818-898-4826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 261QF0400X
CA960000124261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP11580FOtherCANCER DETECTION PROGRAM