1881871721 NPI number — NORTHEAST VALLEY HEALTH CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881871721 NPI number — NORTHEAST VALLEY HEALTH CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST VALLEY HEALTH CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881871721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1172 N. MACLAY AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FERNANDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-898-1388
Provider Business Mailing Address Fax Number:
818-365-4031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13356 ELDRIDGE AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLMAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-362-6182
Provider Business Practice Location Address Fax Number:
818-367-2340
Provider Enumeration Date:
01/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WYARD
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
818-898-1388

Provider Taxonomy Codes

  • Taxonomy code: 261QF0050X , with the licence number:  960001302 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HAP70882F . This is a "FAMILY PACT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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