Basic Information
| Provider Information | |||||||||
| NPI: | 1639776420 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVY CREEK PALLIATIVE CARE, LLC | ||||||||
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| Address1: | PO BOX 130 | ||||||||
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| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360920003 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 HOSPITAL DR STE B | ||||||||
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| City: | WETUMPKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360921626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345675626 | ||||||||
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| ProviderEnumerationDate: | 10/05/2020 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | BRUCE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3345674311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
No ID Information.