Provider Demographics
NPI:1609572890
Name:IVY CREEK FAMILY CARE OF LAKE MARTIN
Entity Type:Organization
Organization Name:IVY CREEK FAMILY CARE OF LAKE MARTIN
Other - Org Name:IVY CREEK URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:H
Authorized Official - Last Name:LANGFORD
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:334-740-9109
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0003
Mailing Address - Country:US
Mailing Address - Phone:334-514-3821
Mailing Address - Fax:334-514-3686
Practice Address - Street 1:5958 HIGHWAY 49 S UNIT K
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-6771
Practice Address - Country:US
Practice Address - Phone:256-825-7821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-31
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty