Provider Demographics
NPI:1790004836
Name:VALLEY HEAD CLINIC LLC
Entity Type:Organization
Organization Name:VALLEY HEAD CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:EJAZ
Authorized Official - Last Name:ATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-451-1250
Mailing Address - Street 1:205 GRAND AVE NW
Mailing Address - Street 2:STE B
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-2107
Mailing Address - Country:US
Mailing Address - Phone:256-979-1515
Mailing Address - Fax:256-979-1517
Practice Address - Street 1:205 GRAND AVE NW
Practice Address - Street 2:STE B
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-2107
Practice Address - Country:US
Practice Address - Phone:256-979-1515
Practice Address - Fax:256-979-1517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16386261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center