Provider Demographics
NPI:1801149505
Name:VALHALLA PLACE, LLC
Entity type:Organization
Organization Name:VALHALLA PLACE, LLC
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
Mailing Address - Street 2:220
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1018
Mailing Address - Country:US
Mailing Address - Phone:651-925-8200
Mailing Address - Fax:
Practice Address - Street 1:2807 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55444-1844
Practice Address - Country:US
Practice Address - Phone:651-925-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN157311041C0700X
MN1063405261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN260163778Medicaid