Provider Demographics
NPI:1245372168
Name:IVY CREEK OF BUTLER, LLC.
Entity type:Organization
Organization Name:IVY CREEK OF BUTLER, LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:CPA (INACTIVE)
Authorized Official - Phone:334-383-2423
Mailing Address - Street 1:300 N COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36037
Mailing Address - Country:US
Mailing Address - Phone:334-382-2681
Mailing Address - Fax:334-383-9884
Practice Address - Street 1:125 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:GEORGIANA
Practice Address - State:AL
Practice Address - Zip Code:36033
Practice Address - Country:US
Practice Address - Phone:334-376-2291
Practice Address - Fax:334-376-3655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11769261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL540003424Medicaid
AL540003424Medicaid