Provider Demographics
NPI:1679904668
Name:IVY LEAVES PLACE, LLC
Entity Type:Organization
Organization Name:IVY LEAVES PLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-808-7172
Mailing Address - Street 1:7199 RENDON BLOODWORTH RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4925
Mailing Address - Country:US
Mailing Address - Phone:817-483-1294
Mailing Address - Fax:
Practice Address - Street 1:7199 RENDON BLOODWORTH RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4925
Practice Address - Country:US
Practice Address - Phone:817-483-1294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5646500178Medicaid