Provider Demographics
NPI:1851362511
Name:IVY HALL, INC
Entity Type:Organization
Organization Name:IVY HALL, INC
Other - Org Name:IVY HALL NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:CARVER
Authorized Official - Last Name:DELOACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-542-6512
Mailing Address - Street 1:301 S WATAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-3546
Mailing Address - Country:US
Mailing Address - Phone:423-542-6512
Mailing Address - Fax:423-542-9311
Practice Address - Street 1:301 S WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-3546
Practice Address - Country:US
Practice Address - Phone:423-542-6512
Practice Address - Fax:423-542-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000025313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440103Medicaid
TN0445469Medicaid
TN7440103Medicaid
1307340001Medicare NSC