Provider Demographics
NPI:1881972503
Name:VALHALLA PLACE BRAINERD LLC
Entity type:Organization
Organization Name:VALHALLA PLACE BRAINERD 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 1:2215 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-5549
Mailing Address - Country:US
Mailing Address - Phone:763-276-4856
Mailing Address - Fax:
Practice Address - Street 1:2215 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-5549
Practice Address - Country:US
Practice Address - Phone:763-276-4856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone