Provider Demographics
NPI:1639776420
Name:IVY CREEK PALLIATIVE CARE, LLC
Entity Type:Organization
Organization Name:IVY CREEK PALLIATIVE CARE, LLC
Other - Org Name:
Other - Org Type:
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:CEO
Authorized Official - Phone:334-567-4311
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:
Mailing Address - Fax:
Practice Address - Street 1:525 HOSPITAL DR STE B
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-1626
Practice Address - Country:US
Practice Address - Phone:334-567-5626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty