NPIMap

Organization Active NPI

Northeast Valley Health Corporation

Doing business as L.a. Mission College Student Health Center

  • Federally Qualified Health Center (FQHC)
  • Sylmar, CA
National Provider Identifier
1154322642
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
L.a. Mission College Student Health Center
Practice address
13356 Eldridge Ave
Sylmar, CA 91342-3200
Phone
(818) 362-6182
Fax
(818) 367-2340
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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Case Manager/Care Coordinator 171M00000X NU

Addresses

Primary practice location

13356 Eldridge Ave
Sylmar, CA 91342-3200

Mailing address

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

Other names 1

  • L.A. MISSION COLLEGE STUDENT 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…
O20170508002553 CA Part A Provider - Federally Qualified Health Center (FQHC) 3173517323 Practice locations: Sylmar, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1154322642. Details of each certification follow.

Federally qualified health center certification: CCN 751967

Legal name
NORTHEAST VALLEY HEALTH CORPORATION
Doing business as
LOS ANGELES MISSION COLLEGE STUDENT HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 9, 2017
Last certification
May 9, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Feb 16, 1971 in CA
Enrollment address
13356 Eldridge Ave
Sylmar, CA 91342-3200

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

National Provider Directory

National Provider Directory
Tax ID family
Jesse Sanders MD28 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

13356 Eldridge Ave
Sylmar, CA 91342
Phone (818) 257-4367

Ownership & related parties

All disclosed owners & managing parties 6

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 OfficerCfo May 21, 1990
Theresa Nitescu Individual Corporate OfficerCoo Sep 15, 1995
Maria a Pacheco Individual Corporate DirectorVice Chairperson - Board of Dire Mar 31, 2014
Kurt Cabrera-Miller Individual Corporate DirectorChairman of the Board of Directo Feb 25, 2013
Theodore Bradpiece Individual Corporate DirectorTreasurer - Board of Director Aug 30, 2010
Kimberly Wyard Individual Corporate OfficerCeo Oct 17, 1974
W-2 Managing EmployeeCeo Oct 17, 1974

Practitioners & affiliated clinicians

Practitioners 16

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 16

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": "1154322642",
    "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": "13356 ELDRIDGE AVE",
            "city": "SYLMAR",
            "state": "CA",
            "postal_code": "913423200",
            "telephone_number": "818-362-6182",
            "fax_number": "818-367-2340"
        }
    ],
    "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": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "L.A. MISSION COLLEGE STUDENT HEALTH CENTER",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "L.A. MISSION COLLEGE STUDENT HEALTH CENTER",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sylmar, CA

Sources for this page

Verify at the official NPI Registry.