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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