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General NPI Number Information
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NPI Number | 1225211709
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Entity Type | Organization
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Legal Business Name | IVY CREEK OF TALLAPOOSA LLC
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Dates
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Enumeration Date | 12/07/2007
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Last Update Date | 04/05/2022
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Provider Practice Location Address
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Address Line | 301 MARIARDEN RD SUITE F
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City | DADEVILLE
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State | AL
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Zip | 36853-6254
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Country | US
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Telephone | 256-825-7050
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Fax | 256-825-7068
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Provider Business Mailing Address
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Address Line | 301 MARIARDEN RD SUITE F
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City | DADEVILLE
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State | AL
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Zip | 36853-6254
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Country | US
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Telephone | 256-825-7050
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Fax | 256-825-7068
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Authorized Official
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Title or Position | HOME HEALTH DIRECTOR
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Name | MRS. PAM TIDWELL
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Credential | RN
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Telephone | 256-397-1440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 017117
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License Number State | AL
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