Provider Demographics
NPI:1962509182
Name:IVY CREEK MEDICAL EQUIPMENT, LLC
Entity Type:Organization
Organization Name:IVY CREEK MEDICAL EQUIPMENT, LLC
Other - Org Name:IVY CREEK MEDICAL EQUIPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
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:256-825-0677
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:256-825-0677
Mailing Address - Fax:256-827-0803
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:256-825-0677
Practice Address - Fax:256-827-0803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
AL715332B00000X
AL1307332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009940367Medicaid
AL51538455OtherBCBS OF ALABAMA
AL009940367Medicaid