NPIMap

Organization Active NPI

Northeast Valley Health Corporation

Doing business as Mobile Health Center

  • Federally Qualified Health Center (FQHC)
  • San Fernando, CA
National Provider Identifier
1679332647
Registry record updated Mar 13, 2024
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
Mobile Health Center
Practice address
1172 N Maclay Ave
San Fernando, CA 91340-1328
Phone
(818) 898-1388
Fax
(818) 270-9585
NPI assigned
Mar 13, 2024
Last updated
Mar 13, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 13, 2024

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

1172 N Maclay Ave
San Fernando, CA 91340-1328

Mailing address

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

Other names 1

  • Mobile Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090804000312 CA Part A Provider - Federally Qualified Health Center (FQHC) 3173517323 1 other NPI on this enrollment
Practice locations: San Fernando, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1679332647. Details of each certification follow.

Federally qualified health center certification: CCN 921175

Legal name
NORTHEAST VALLEY HEALTH CORPORATION
Doing business as
MOBILE HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 12, 2019
Last certification
Sep 12, 2019
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Feb 16, 1971 in CA
Enrollment address
1172 N Maclay Ave
San Fernando, CA 91340-1328

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 1

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

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

Ownership & related parties

All disclosed owners & managing parties 11

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
Kathryn Proctor Individual W-2 Managing EmployeeClinic Administrator Jun 27, 2007
Mark Stokes Individual Corporate DirectorBoard Member Sep 8, 2015
Theresa Nitescu Individual Corporate OfficerCoo Sep 15, 1995
Kurt Cabrera-Miller Individual Corporate DirectorChairperson of the Board Feb 25, 2013
Bethany Jones Individual Corporate DirectorSecretary of the Board Jan 1, 2026
Christopher Reed Individual Corporate OfficerCeo May 29, 2025
Christine L Park Individual Corporate OfficerCmo Jul 17, 2003
Juan Vargas Individual Corporate DirectorBoard Member Jan 1, 2026
Theodore Bradpiece Individual Corporate DirectorVice Chair Person Jan 1, 2026
Emily Mijangos Individual Corporate DirectorTreasurer of the Board Jan 1, 2026

Owners & managing parties with NPI records 2

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

NPI Registry JSON

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

{
    "created_epoch": "1710288000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710288000000",
    "number": "1679332647",
    "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": "818-270-9585"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1172 N MACLAY AVE",
            "city": "SAN FERNANDO",
            "state": "CA",
            "postal_code": "913401328",
            "telephone_number": "818-898-1388",
            "fax_number": "818-270-9585"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST VALLEY HEALTH CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-03-13",
        "last_updated": "2024-03-13",
        "certification_date": "2024-03-13",
        "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"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mobile Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Fernando, CA

Sources for this page

Verify at the official NPI Registry.