Organization
IVY CREEK OF ELMORE, LLC
Active
Organization
IVY CREEK OF ELMORE, LLC
Active
Other names
IVY CREEK FAMILY CARE OF HOLTVILLE
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JADE LANE (CREDENTIALING MANAGER)
(334) 567-4311
Entity
Organization
Contact information
Practice address
4412 HOGAN RD, DEATSVILLE, AL 36022-3400
(334) 514-4851
(334) 543-4854
Mailing address
PO BOX 130, WETUMPKA, AL 36092-0003
(334) 514-4851
(334) 543-4854
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01D2153925
CLIA
AL
01
—
13474
MEDICARE A
AL
01
—
1608
MEDICARE B
AL
05
—
231138
—
AL
Enumeration date
04/09/2018
Last updated
03/20/2025
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