Provider Demographics
NPI:1780074849
Name:VALHALLA PLACE CLINIC, P.A.
Entity type:Organization
Organization Name:VALHALLA PLACE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-365-6112
Mailing Address - Street 1:6043 HUDSON RD STE 220
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1033
Mailing Address - Country:US
Mailing Address - Phone:651-925-8200
Mailing Address - Fax:652-925-8201
Practice Address - Street 1:6043 HUDSON RD STE 220
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1033
Practice Address - Country:US
Practice Address - Phone:651-925-8200
Practice Address - Fax:652-925-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center