Healthcare Provider Details

I. General information

NPI: 1720736705
Provider Name (Legal Business Name): VALHALLA MEDICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92-18 ROCKAWAY BEACH BLVD
ROCKAWAY BEACH NY
11693
US

IV. Provider business mailing address

92-18 ROCKAWAY BEACH BLVD
ROCKAWAY BEACH NY
11693
US

V. Phone/Fax

Practice location:
  • Phone: 516-266-6186
  • Fax: 445-800-8689
Mailing address:
  • Phone: 516-266-6186
  • Fax: 445-800-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILIP D'AGOSTINO
Title or Position: CEO
Credential:
Phone: 516-266-6186