1932130002 NPI number — IVY CREEK OF TALLAPOOSA LLC

Table of content: (NPI 1932130002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932130002 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:
1932130002
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:
PO BOX 129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DADEVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36853-0129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-825-7871
Provider Business Mailing Address Fax Number:
256-825-5742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 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:
36853-0129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-825-7871
Provider Business Practice Location Address Fax Number:
256-825-5742
Provider Enumeration Date:
07/06/2006

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: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 540003420 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01D0920584 . This is a "CLIA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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