Provider Demographics
NPI:1659685345
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:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-825-7821
Mailing Address - Street 1:201 MARIARDEN RD
Mailing Address - Street 2:
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVY CREEK OF TALLAPOOSA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-05
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALH6202275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL010144OtherBC/BS
ALHOS0052HMedicaid
ALHOS0052HMedicaid