Provider Demographics
NPI:1811583370
Name:IVY GATE LLC
Entity Type:Organization
Organization Name:IVY GATE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALEXANDRIA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:HILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:205-266-1956
Mailing Address - Street 1:5017 KINGS DR
Mailing Address - Street 2:
Mailing Address - City:ADAMSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35005-1814
Mailing Address - Country:US
Mailing Address - Phone:205-266-1956
Mailing Address - Fax:
Practice Address - Street 1:5017 KINGS DR
Practice Address - Street 2:
Practice Address - City:ADAMSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35005-1814
Practice Address - Country:US
Practice Address - Phone:205-266-1956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances