Organization
IVY CREEK OF TALLAPOOSA LLC
Active
Other names
Lake Martin Family Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL D BRUCE (CEO)
(334) 567-4311
Entity
Organization
Contact information
Practice address
301 MARIARDEN RD, DADEVILLE, AL 36853-0129
(256) 825-7871
(256) 825-5742
Mailing address
PO BOX 129, DADEVILLE, AL 36853-0129
(256) 825-7871
(256) 825-5742
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01D0920584
CLIA
AL
05
—
540003420
—
AL
Enumeration date
07/06/2006
Last updated
04/05/2022
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