Provider Demographics
NPI:1225211709
Name:IVY CREEK OF TALLAPOOSA LLC
Entity Type:Organization
Organization Name:IVY CREEK OF TALLAPOOSA LLC
Other - Org Name:LAKE MARTIN HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOME HEALTH DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:256-397-1440
Mailing Address - Street 1:301 MARIARDEN RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:DADEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36853-6254
Mailing Address - Country:US
Mailing Address - Phone:256-825-7050
Mailing Address - Fax:256-825-7068
Practice Address - Street 1:301 MARIARDEN RD
Practice Address - Street 2:SUITE F
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-6254
Practice Address - Country:US
Practice Address - Phone:256-825-7050
Practice Address - Fax:256-825-7068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL017117251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALLAK7117AMedicaid
ALLAK7117AMedicaid