NPIMap

Organization Active NPI

Northeast Valley Health Corporation

Doing business as Canoga Park Health Center

  • Federally Qualified Health Center (FQHC)
  • Canoga Park, CA
National Provider Identifier
1740281120
Registry record updated Mar 3, 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
Canoga Park Health Center
Practice address
7107 Remmet Ave
Canoga Park, CA 91303-2016
Phone
(818) 340-3570
Fax
(818) 702-9578
NPI assigned
Aug 9, 2005
Last updated
Mar 3, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 3, 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
Community Health Clinic/Center 261QC1500X 9600963 CA
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Case Manager/Care Coordinator 171M00000X NU

Addresses

Primary practice location

7107 Remmet Ave
Canoga Park, CA 91303-2016

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
W14819BOtherMIN

Other names 1

  • Canoga Park 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…
O20070214000420 CA Part A Provider - Federally Qualified Health Center (FQHC) 3173517323 Practice locations: Canoga Park, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1740281120. Details of each certification follow.

Federally qualified health center certification: CCN 551845

Legal name
NORTHEAST VALLEY HEALTH CORPORATION
Doing business as
CANOGA PARK HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 1, 1998
Last certification
Jan 1, 1998
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Feb 16, 1971 in CA
Enrollment address
7107 Remmet Ave
Canoga Park, CA 91303-2016

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

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 OfficerChief Financial Officer May 21, 1990
Mark Stokes Individual Corporate OfficerSecretary of the Board Sep 8, 2015
Patricia Torres Individual W-2 Managing Employee Jul 6, 2015
Theresa Nitescu Individual Corporate OfficerCoo Sep 15, 1995
Kurt Cabrera-Miller Individual Corporate OfficerChair Person of the Board Feb 25, 2013
Christine L Park Individual Corporate OfficerC.M.O. Jul 17, 2003
Juan Vargas Individual Corporate OfficerTreasurer of the Board Jan 1, 2018
Theodore Bradpiece Individual Corporate Director Aug 30, 2010
Kimberly Wyard Individual Corporate OfficerC.E.O. Oct 17, 1974

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 13

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 13

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": "1646265600000",
    "number": "1740281120",
    "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": "7107 REMMET AVE",
            "city": "CANOGA PARK",
            "state": "CA",
            "postal_code": "913032016",
            "telephone_number": "818-340-3570",
            "fax_number": "818-702-9578"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEAST VALLEY HEALTH CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-09",
        "last_updated": "2022-03-03",
        "certification_date": "2022-03-03",
        "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": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "CA",
            "license": "9600963",
            "primary": false
        },
        {
            "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": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MIN",
            "identifier": "W14819B",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Canoga Park Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canoga Park, CA

Sources for this page

Verify at the official NPI Registry.