Provider Demographics
NPI:1356988349
Name:IVY AT DEER LODGE LLC
Entity type:Organization
Organization Name:IVY AT DEER LODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MORRIS
Authorized Official - Last Name:COANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-912-9260
Mailing Address - Street 1:9429 HARDING AVE # 141
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE
Mailing Address - State:FL
Mailing Address - Zip Code:33154-2803
Mailing Address - Country:US
Mailing Address - Phone:305-912-9260
Mailing Address - Fax:
Practice Address - Street 1:1100 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722-1829
Practice Address - Country:US
Practice Address - Phone:406-846-1655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-09
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies