Basic Information
Provider Information | |||||||||
NPI: | 1093838880 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IVY CREEK OF ELMORE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | WETUMPKA | ||||||||
State: | AL | ||||||||
PostalCode: | 360921625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3345674311 | ||||||||
FaxNumber: | 3345673361 | ||||||||
Practice Location | |||||||||
Address1: | 74186 TALLASSEE HWY | ||||||||
Address2: |   | ||||||||
City: | WETUMPKA | ||||||||
State: | AL | ||||||||
PostalCode: | 360925643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3345670346 | ||||||||
FaxNumber: | 3345670855 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FAULK | ||||||||
AuthorizedOfficialFirstName: | GORDON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3345674311 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 00011939 | AL | Y |   | Managed Care Organizations | Preferred Provider Organization |   |
ID Information
ID | Type | State | Issuer | Description | 529913110 | 05 | AL |   | MEDICAID |