Provider Demographics
NPI:1578060349
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:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JADE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
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:334-514-4851
Mailing Address - Fax:334-543-4854
Practice Address - Street 1:4412 HOGAN RD
Practice Address - Street 2:
Practice Address - City:DEATSVILLE
Practice Address - State:AL
Practice Address - Zip Code:36022-3400
Practice Address - Country:US
Practice Address - Phone:334-514-4851
Practice Address - Fax:334-543-4854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1608OtherMEDICARE B
AL01D2153925OtherCLIA
AL231138Medicaid
AL13474OtherMEDICARE A