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General NPI Number Information
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NPI Number | 1811583370
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Entity Type | Organization
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Legal Business Name | IVY GATE LLC
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Dates
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Enumeration Date | 12/17/2020
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Last Update Date | 12/17/2020
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Provider Practice Location Address
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Address Line | 5017 KINGS DR
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City | ADAMSVILLE
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State | AL
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Zip | 35005-1814
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Country | US
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Telephone | 205-266-1956
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Fax |
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Provider Business Mailing Address
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Address Line | 5017 KINGS DR
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City | ADAMSVILLE
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State | AL
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Zip | 35005-1814
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Country | US
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Telephone | 205-266-1956
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. ALEXANDRIA NICOLE HILLIARD
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Credential | LPN
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Telephone | 205-266-1956
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number |
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License Number State |
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