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General NPI Number Information
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NPI Number | 1558868323
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Entity Type | Organization
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Legal Business Name | IVY CREEK OF ELMORE, LLC
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Dates
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Enumeration Date | 04/09/2018
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Last Update Date | 03/20/2025
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Provider Practice Location Address
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Address Line | 2256 GILMER AVE
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City | TALLASSEE
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State | AL
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Zip | 36078-7114
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Country | US
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Telephone | 334-283-2542
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 130
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City | WETUMPKA
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State | AL
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Zip | 36092-0003
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Country | US
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Telephone | 334-283-2542
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | MRS. JADE LANE
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Credential |
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Telephone | 334-567-4311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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