NPIMap

Organization Active NPI

Northeast Valley Health Corporation

Doing business as Pacoima Health Center

  • Federally Qualified Health Center (FQHC)
  • Pacoima, CA
National Provider Identifier
1114928595
Registry record updated Feb 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
NORTHEAST VALLEY HEALTH CORPORATION
Doing business as
Pacoima Health Center
Practice address
12756 Van Nuys Blvd
Pacoima, CA 91331-1626
Phone
(818) 896-0531
Fax
(818) 896-5850
NPI assigned
Aug 9, 2005
Last updated
Feb 22, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 22, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Kimberly Wyard
Title
Chief Executive Officer
Phone
(818) 898-1388

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Case Manager/Care CoordinatorGroup: 193200000X MULTI-SPECIALTY GROUP 171M00000X
Community Health Clinic/Center 261QC1500X 9600189 CA
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

12756 Van Nuys Blvd
Pacoima, CA 91331-1626

Mailing address

1172 N Maclay Ave
San Fernando, CA 91340-1328
Phone (818) 898-1388

Other names 1

  • PACOIMA HEALTH CENTER Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040412001067 CA Part B Supplier - Clinic/Group Practice 3173517323 Receives reassigned benefits from 235 practitioners
16 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Van Nuys, CA; Valencia, CA; Sylmar, CA; Pacoima, CA; Sun Valley, CA; Santa Clarita, CA; San Fernando, CA; Canoga Park, CA…
O20070214000418 CA Part A Provider - Federally Qualified Health Center (FQHC) 3173517323 Practice locations: Pacoima, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114928595. Details of each certification follow.

Federally qualified health center certification: CCN 051899

Legal name
NORTHEAST VALLEY HEALTH CORPORATION
Doing business as
PACOIMA HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Feb 16, 1971 in CA
Enrollment address
12756 Van Nuys Blvd
Pacoima, CA 91331-1626

Other NPIs with the same Medicare PAC ID 13

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 13

Other NPIs on the same Medicare enrollment 16

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 16

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0666584Pacoima Health Center12756 Van Nuys Boulevard, Pacoima, CA 91331Provider-performed microscopyAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Northeast Vall Ey28 organizations share this tax ID, including this one

Other organizations with this tax ID 27

Organizations that report the same tax identification number in the National Provider Directory.

View all 27

Locations

17909 Soledad Canyon Rd
Fl 2
Santa Clarita, CA 91387
Phone (661) 673-8888

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Patricia Moraga Individual Corporate OfficerC.F.O. May 21, 1990
Yanira Valencia Individual W-2 Managing EmployeeClinic Administrator Apr 17, 2006
Cynthia Guerrero Individual Corporate DirectorVice Chairperson Nov 25, 2019
Theresa Nitescu Individual Corporate OfficerC.O.O. May 21, 1990
Richard Galvan Individual Corporate DirectorSecretary Feb 25, 2019
Kurt Cabrera-Miller Individual Corporate DirectorBoard Member Feb 25, 2013
Christine L Park Individual Corporate OfficerCmo Jul 17, 2003
Theodore Bradpiece Individual Corporate DirectorTreasurer Aug 30, 2010
Kimberly Wyard Individual Corporate OfficerC.E.O. Oct 17, 1974

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1123545600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1645488000000",
    "number": "1114928595",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1172 N MACLAY AVE",
            "city": "SAN FERNANDO",
            "state": "CA",
            "postal_code": "913401328",
            "telephone_number": "818-898-1388",
            "fax_number": "818-365-4031"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12756 VAN NUYS BLVD",
            "city": "PACOIMA",
            "state": "CA",
            "postal_code": "913311626",
            "telephone_number": "818-896-0531",
            "fax_number": "818-896-5850"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST VALLEY HEALTH CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-09",
        "last_updated": "2022-02-22",
        "certification_date": "2022-02-22",
        "status": "A",
        "authorized_official_last_name": "WYARD",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "818-898-1388",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "171M00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Case Manager/Care Coordinator",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "CA",
            "license": "9600189",
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PACOIMA HEALTH CENTER",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PACOIMA HEALTH CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pacoima, CA

Sources for this page

Verify at the official NPI Registry.