Healthcare Provider Details

I. General information

NPI: 1790004836
Provider Name (Legal Business Name): VALLEY HEAD CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 GRAND AVE NW STE B
FORT PAYNE AL
35967-2107
US

IV. Provider business mailing address

205 GRAND AVE NW STE B
FORT PAYNE AL
35967-2107
US

V. Phone/Fax

Practice location:
  • Phone: 256-979-1515
  • Fax: 256-979-1517
Mailing address:
  • Phone: 256-979-1515
  • Fax: 256-979-1517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number16386
License Number StateAL

VIII. Authorized Official

Name: MUHAMMAD EJAZ ATA
Title or Position: OWNER
Credential: M.D
Phone: 256-451-1250