Provider Demographics
NPI:1396066650
Name:IVYCREEK OF ELMORE LLC
Entity type:Organization
Organization Name:IVYCREEK OF ELMORE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
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:334-567-4311
Mailing Address - Fax:334-567-4312
Practice Address - Street 1:41 CAMBRIDGE CT
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36093-1261
Practice Address - Country:US
Practice Address - Phone:334-567-3309
Practice Address - Fax:334-567-3361
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVYCREEK OF ELMORE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-21
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL540003434Medicaid
AL102G701614Medicare PIN