Provider Demographics
NPI:1932130002
Name:IVY CREEK OF TALLAPOOSA LLC
Entity Type:Organization
Organization Name:IVY CREEK OF TALLAPOOSA LLC
Other - Org Name:LAKE MARTIN FAMILY MEDICINE
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:334-567-4311
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:DADEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36853-0129
Mailing Address - Country:US
Mailing Address - Phone:256-825-7871
Mailing Address - Fax:256-825-5742
Practice Address - Street 1:301 MARIARDEN RD
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-0129
Practice Address - Country:US
Practice Address - Phone:256-825-7871
Practice Address - Fax:256-825-5742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL540003420Medicaid
AL01D0920584OtherCLIA
AL540003420Medicaid