Provider Demographics
NPI:1093838880
Name:IVY CREEK OF ELMORE, LLC
Entity Type:Organization
Organization Name:IVY CREEK OF ELMORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:FAULK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-567-4311
Mailing Address - Street 1:500 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-1625
Mailing Address - Country:US
Mailing Address - Phone:334-567-4311
Mailing Address - Fax:334-567-3361
Practice Address - Street 1:74186 TALLASSEE HWY
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-5643
Practice Address - Country:US
Practice Address - Phone:334-567-0346
Practice Address - Fax:334-567-0855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00011939305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529913110Medicaid