# NORTHEAST VALLEY HEALTH CORPORATION

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1447437462
- **Authorized official:** MRS. KIMBERLY WYARD (CHIEF EXECUTIVE OFFICER)
- **Authorized official phone:** (818) 898-1388

## Contact information

- **Practice address:** 12756 VAN NUYS BOULEVARD, PACOIMA, CA 91331
- **Practice address phone:** (818) 896-0531
- **Practice address fax:** (818) 896-5850
- **Mailing address:** 1172 N. MACLAY AVE., SAN FERNANDO, CA 91340
- **Mailing address phone:** (818) 898-1388
- **Mailing address fax:** (818) 365-4031

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 171M00000X | Case Manager/Care Coordinator | — | — | — |
| 261QF0400X | Federally Qualified Health Center (FQHC) | — | — | — |
| 261QM2500X | Medical Specialty Clinic/Center | 960000189 | CA | Yes |

## Other

- **Enumeration date:** 01/22/2008
- **Last updated:** 02/23/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | BCP11838F | CANCER DETECTION PROGRAM | CA |