NPIMap

Organization Active NPI

Ivy Creek of Elmore, LLC

  • Preferred Provider Organization
  • Wetumpka, AL
National Provider Identifier
1093838880
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Preferred Provider OrganizationTaxonomy code 305R00000X
License
00011939 Issued in AL
Legal business name
IVY CREEK OF ELMORE, LLC
Practice address
74186 Tallassee Hwy
Wetumpka, AL 36092-5643
Phone
(334) 567-0346
Fax
(334) 567-0855
NPI assigned
Apr 9, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gordon Faulk
Title
Ceo
Phone
(334) 567-4311

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Preferred Provider Organization 305R00000X 00011939 AL Primary

Addresses

Primary practice location

74186 Tallassee Hwy
Wetumpka, AL 36092-5643

Mailing address

500 Hospital Dr
Wetumpka, AL 36092-1625
Phone (334) 567-4311

Other identifiers 1

IdentifierTypeStateIssuer
529913110MedicaidAL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20051027001031 AL Part B Supplier - Clinic/Group Practice 8426075508 Receives reassigned benefits from 183 practitioners
18 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Deatsville, AL; Tallassee, AL; Wetumpka, AL

Other NPIs on the same Medicare enrollment 14

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 14

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176076800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1093838880",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "500 HOSPITAL DR",
            "city": "WETUMPKA",
            "state": "AL",
            "postal_code": "360921625",
            "telephone_number": "334-567-4311",
            "fax_number": "334-567-3361"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "74186 TALLASSEE HWY",
            "city": "WETUMPKA",
            "state": "AL",
            "postal_code": "360925643",
            "telephone_number": "334-567-0346",
            "fax_number": "334-567-0855"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVY CREEK OF ELMORE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-09",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "FAULK",
        "authorized_official_first_name": "GORDON",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "334-567-4311"
    },
    "taxonomies": [
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": "AL",
            "license": "00011939",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "529913110",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wetumpka, AL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.