Provider Demographics
NPI:1255426383
Name:NORTHWEST VALLEY FAMILY MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:NORTHWEST VALLEY FAMILY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTINA
Authorized Official - Middle Name:BARTE
Authorized Official - Last Name:MASONGSONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-388-1951
Mailing Address - Street 1:19182 DUNURE PLACE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326
Mailing Address - Country:US
Mailing Address - Phone:818-368-2859
Mailing Address - Fax:661-259-8295
Practice Address - Street 1:17909 SOLEDAD CANYON RD # 100
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91387-3210
Practice Address - Country:US
Practice Address - Phone:661-367-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70428207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101260Medicaid
CAGR0101261Medicaid
W17326AMedicare ID - Type Unspecified
W17326Medicare ID - Type Unspecified
CAGR0101261Medicaid