=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578060349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IVY CREEK OF ELMORE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2018
-----------------------------------------------------
Last Update Date | 03/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4412 HOGAN RD
-----------------------------------------------------
City | DEATSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36022-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-514-4851
-----------------------------------------------------
Fax | 334-543-4854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 130
-----------------------------------------------------
City | WETUMPKA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36092-0003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-514-4851
-----------------------------------------------------
Fax | 334-543-4854
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | MRS. JADE LANE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 334-567-4311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------