1598783904 NPI number — IVY CREEK OF TALLAPOOSA, LLC

Table of content: (NPI 1598783904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598783904 NPI number — IVY CREEK OF TALLAPOOSA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IVY CREEK OF TALLAPOOSA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598783904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 MARIARDEN RD
Provider Second Line Business Mailing Address:
P.O BOX 629
Provider Business Mailing Address City Name:
DADEVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36853-6244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-825-7821
Provider Business Mailing Address Fax Number:
256-825-5899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 MARIARDEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DADEVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36853-6244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-825-7821
Provider Business Practice Location Address Fax Number:
256-825-5899
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRUCE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
334-567-4311

Provider Taxonomy Codes

  • Taxonomy code: 282NR1301X , with the licence number:  11872 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01D0641802 . This is a "CLIA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529916200 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: BCBS . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: HOS0052H , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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