Provider Demographics
NPI:1154642684
Name:IVY CREEK OF ELMORE, LLC
Entity Type:Organization
Organization Name:IVY CREEK OF ELMORE, LLC
Other - Org Name:D/B/A ENGLAND'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
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:SUITE B
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:334-567-4312
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-1625
Practice Address - Country:US
Practice Address - Phone:334-567-4311
Practice Address - Fax:334-567-4312
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVY CREEK OF ELMORE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-18
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102G709815Medicare PIN