Organization
IVY CREEK OF ELMORE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GORDON FAULK (CEO)
(334) 567-4311
Entity
Organization
Contact information
Practice address
74186 TALLASSEE HWY, WETUMPKA, AL 36092-5643
(334) 567-0346
(334) 567-0855
Mailing address
500 HOSPITAL DR, WETUMPKA, AL 36092-1625
(334) 567-4311
(334) 567-3361
Taxonomy
Speciality
Code
Description
License number
State
305R00000X
Preferred Provider Organization
Primary
00011939
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
529913110
—
AL
Enumeration date
04/09/2007
Last updated
08/22/2020
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