Provider Demographics
NPI:1972850741
Name:IVY CREEK FAMILY CARE
Entity Type:Organization
Organization Name:IVY CREEK FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:FAULK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-361-7316
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:AUTAUGAVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36003-0490
Mailing Address - Country:US
Mailing Address - Phone:334-361-7316
Mailing Address - Fax:334-361-7858
Practice Address - Street 1:201 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:AUTAUGAVILLE
Practice Address - State:AL
Practice Address - Zip Code:36003-2535
Practice Address - Country:US
Practice Address - Phone:334-361-7316
Practice Address - Fax:334-361-7858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center