Provider Demographics
NPI:1598783904
Name:IVY CREEK OF TALLAPOOSA, LLC
Entity Type:Organization
Organization Name:IVY CREEK OF TALLAPOOSA, LLC
Other - Org Name:LAKE MARTIN COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-567-4311
Mailing Address - Street 1:201 MARIARDEN RD
Mailing Address - Street 2:P.O BOX 629
Mailing Address - City:DADEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36853-6244
Mailing Address - Country:US
Mailing Address - Phone:256-825-7821
Mailing Address - Fax:256-825-5899
Practice Address - Street 1:201 MARIARDEN RD
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-6244
Practice Address - Country:US
Practice Address - Phone:256-825-7821
Practice Address - Fax:256-825-5899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11872282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01D0641802OtherCLIA
AL529916200Medicaid
ALBCBSOtherBLUE CROSS BLUE SHIELD
ALHOS0052HMedicaid