Basic Information
| Provider Information | |||||||||
| NPI: | 1891332896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVY AT GREAT FALLS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9429 HARDING AVE # 141 | ||||||||
| Address2: | |||||||||
| City: | SURFSIDE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331542803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059129260 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1130 17TH AVE S | ||||||||
| Address2: | |||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594054523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067714500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2019 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | COANE | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | MORRIS | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3059129260 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.