1093838880 NPI number — IVY CREEK OF ELMORE, LLC

Table of content: (NPI 1093838880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093838880 NPI number — IVY CREEK OF ELMORE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IVY CREEK OF ELMORE, 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:
1093838880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WETUMPKA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36092-1625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-567-4311
Provider Business Mailing Address Fax Number:
334-567-3361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
74186 TALLASSEE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WETUMPKA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36092-5643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-567-0346
Provider Business Practice Location Address Fax Number:
334-567-0855
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FAULK
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
334-567-4311

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  00011939 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 529913110 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com