Organization
IVY CREEK OF ELMORE LLC
Active
Organization
IVY CREEK OF ELMORE LLC
Active
Other names
WETUMPKA FAMILY RURAL HEALTH CLINIC
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL D BRUCE (CEO)
(334) 567-4311
Entity
Organization
Contact information
Practice address
815 JACKSON TRACE RD, WETUMPKA, AL 36092-1504
(334) 567-2882
(334) 567-3361
Mailing address
PO BOX 130, WETUMPKA, AL 36092-0003
(334) 567-2882
(334) 514-6747
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
013434
MEDICARE
AL
01
—
01D0891738
CLIA
AL
01
—
102G701614
MEDICARE
AL
05
—
540003434
—
AL
Enumeration date
03/23/2011
Last updated
04/05/2022
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