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General NPI Number Information
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NPI Number | 1659685345
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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 | 08/05/2010
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Last Update Date | 08/21/2020
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Provider Practice Location Address
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Address Line | 201 MARIARDEN RD
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City | DADEVILLE
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State | AL
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Zip | 36853-6244
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Country | US
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Telephone | 256-825-7821
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Fax |
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Provider Business Mailing Address
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Address Line | 201 MARIARDEN RD
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City | DADEVILLE
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State | AL
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Zip | 36853-6244
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Country | US
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Telephone | 256-825-7821
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | MR. MICHAEL BRUCE
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Credential |
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Telephone | 256-825-7821
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 275N00000X
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Taxonomy Name | Medicare Defined Swing Bed Hospital Unit
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License Number | H6202
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License Number State | AL
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