Provider Demographics
NPI:1316246812
Name:IVY CREEK OF ELMORE LLC
Entity type:Organization
Organization Name:IVY CREEK OF ELMORE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-567-4311
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0003
Mailing Address - Country:US
Mailing Address - Phone:334-567-2882
Mailing Address - Fax:334-514-6747
Practice Address - Street 1:815 JACKSON TRACE RD
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-1504
Practice Address - Country:US
Practice Address - Phone:334-567-2882
Practice Address - Fax:334-567-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL540003434Medicaid
AL013434OtherMEDICARE
AL01D0891738OtherCLIA
AL102G701614OtherMEDICARE