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Northeast Valley Health Corporation

Organization Active NPI Federally Qualified Health Center (FQHC) · Pacoima, CA

NPI 1114928595 · NPPES record last updated Feb 22, 2022

Key facts

NPI
1114928595
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
NORTHEAST VALLEY HEALTH CORPORATION
Practice address
12756 Van Nuys Blvd
Pacoima, CA 91331-1626
Phone
(818) 896-0531
Fax
(818) 896-5850
NPI assigned
Aug 9, 2005
Organization subpart
No

Authorized official

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

Owners & managing parties with NPI records 1

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

Other NPIs on the same Medicare enrollment 16

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

Other NPIs with the same Medicare PAC ID 13

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

Corporate family (same tax ID) 27

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

View all 27

Practitioners 91

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 91

Laboratory certificates & supplier records

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0666584Pacoima Health Center
12756 Van Nuys Boulevard, Pacoima, CA 91331		Provider-performed microscopyAug 31, 2026

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in CA

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
Corporation · Non-profit
Incorporated
Feb 16, 1971 in CA
Enrollment address
12756 Van Nuys Blvd
Pacoima, CA 91331-1626

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 Officer
C.F.O.		 May 21, 1990
Yanira Valencia
Individual 		W-2 Managing Employee
Clinic Administrator		 Apr 17, 2006
Cynthia Guerrero
Individual 		Corporate Director
Vice Chairperson		 Nov 25, 2019
Theresa Nitescu
Individual 		Corporate Officer
C.O.O.		 May 21, 1990
Richard Galvan
Individual 		Corporate Director
Secretary		 Feb 25, 2019
Kurt Cabrera-Miller
Individual 		Corporate Director
Board Member		 Feb 25, 2013
Christine L Park
Individual 		Corporate Officer
Cmo		 Jul 17, 2003
Theodore Bradpiece
Individual 		Corporate Director
Treasurer		 Aug 30, 2010
Kimberly Wyard
Individual 		Corporate Officer
C.E.O.		 Oct 17, 1974

Medicare enrollment records

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

National Provider Directory

Tax ID family
Northeast Vall Ey (28 organizations share this tax ID)

Locations

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

Specialties & licenses

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

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 identifiers

IdentifierTypeStateIssuer
W14819AOtherMIN

Other names

  • PACOIMA HEALTH CENTER Doing business as

Other providers in Pacoima, CA

All providers in Pacoima, CA · Federally Qualified Health Center (FQHC) in California

Sources for this page

Verify at the official NPI Registry.