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General NPI Number Information
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NPI Number | 1972850741
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Entity Type | Organization
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Legal Business Name | IVY CREEK FAMILY CARE
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Dates
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Enumeration Date | 08/10/2012
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Last Update Date | 09/28/2012
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Provider Practice Location Address
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Address Line | 201 S WASHINGTON ST
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City | AUTAUGAVILLE
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State | AL
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Zip | 36003-2535
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Country | US
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Telephone | 334-361-7316
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Fax | 334-361-7858
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Provider Business Mailing Address
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Address Line | PO BOX 490
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City | AUTAUGAVILLE
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State | AL
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Zip | 36003-0490
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Country | US
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Telephone | 334-361-7316
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Fax | 334-361-7858
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Authorized Official
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Title or Position | CEO
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Name | JAMES GORDON FAULK
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Credential |
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Telephone | 334-361-7316
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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