1801149505 NPI number — VALHALLA PLACE, LLC

Table of content: (NPI 1801149505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801149505 NPI number — VALHALLA PLACE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALHALLA PLACE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801149505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6043 HUDSON RD
Provider Second Line Business Mailing Address:
220
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-1018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-925-8200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2807 BROOKDALE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55444-1844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-925-8200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
612-326-7555

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  15731 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X , with the licence number: 1063405 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 260163778 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".