Provider Demographics
NPI:1255533642
Name:IVY CREEK OF ELMORE, LLC
Entity type:Organization
Organization Name:IVY CREEK OF ELMORE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRINE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:334-567-7710
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0003
Mailing Address - Country:US
Mailing Address - Phone:334-567-7710
Mailing Address - Fax:334-567-3227
Practice Address - Street 1:500 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-1625
Practice Address - Country:US
Practice Address - Phone:334-567-7710
Practice Address - Fax:334-567-3227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11797251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALELM7116AMedicaid
AL017116Medicare Oscar/Certification