NPIMap

Organization Active NPI

Ivy Creek of Tallapoosa LLC

Doing business as Lake Martin Home Health

  • Home Health Agency
  • Dadeville, AL
National Provider Identifier
1225211709
Registry record updated Apr 5, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Home Health AgencyTaxonomy code 251E00000X
License
017117 Issued in AL
Legal business name
IVY CREEK OF TALLAPOOSA LLC
Doing business as
Lake Martin Home Health
Practice address
301 Mariarden Rd
Suite F
Dadeville, AL 36853-6254
Phone
(256) 825-7050
Fax
(256) 825-7068
NPI assigned
Dec 7, 2007
Last updated
Apr 5, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 5, 2022

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

Authorized official

Name
Mrs. Pam Tidwell, RN
Title
Home Health Director
Phone
(256) 397-1440

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Home Health Agency 251E00000X 017117 AL Primary

Addresses

Primary practice location

301 Mariarden Rd
Suite F
Dadeville, AL 36853-6254

Mailing address

301 Mariarden Rd
Suite F
Dadeville, AL 36853-6254
Phone (256) 825-7050

Other identifiers 1

IdentifierTypeStateIssuer
LAK7117AMedicaidAL

Other names 1

  • LAKE MARTIN HOME HEALTH Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030513000003 AL Part A Provider - Home Health Agency 8123938719 Practice locations: Dadeville, AL; Alexander City, AL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1225211709. Details of each certification follow.

Home health agency certification: CCN 017117

Legal name
IVY CREEK OF TALLAPOOSA LLC
Doing business as
LAKE MARTIN HOME HEALTH
Certification status
Active
Provider type (POS)
Home health agency
Participating since
Jul 29, 1993
Last certification
Jun 25, 2021
Ownership / control type
Proprietary
Organization structure
LLCProprietary
Incorporated
May 15, 2001 in AL
Enrollment address
729 E South St
Dadeville, AL 36853-2033

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Home health agency

Medicare Care Compare
Listed as
Lake Martin Home HealthCCN 017117 · All quality measures
Overall star rating
2.5 of 5
Ownership
Proprietary
Certified
Jul 29, 1993
Medicare certification status
ActiveFrom the Provider of Services file
Services
Nursing, Home health aide, Physical therapy, Speech pathology

National Provider Directory

National Provider Directory
Tax ID family
Ivy Creek of Tallapoosa8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Kathrine Bryan Individual Corporate DirectorDirector Sep 1, 2020
Operational/Managerial Control Sep 1, 2020
Michael David Bruce Individual 5% Or Greater Direct Ownership InterestOwner/Ceo Jul 1, 2001 100%
Corporate Director May 13, 2003
W-2 Managing Employee Jul 1, 2001

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 10

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1196985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1649116800000",
    "number": "1225211709",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "301 MARIARDEN RD",
            "address_2": "SUITE F",
            "city": "DADEVILLE",
            "state": "AL",
            "postal_code": "368536254",
            "telephone_number": "256-825-7050",
            "fax_number": "256-825-7068"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "301 MARIARDEN RD",
            "address_2": "SUITE F",
            "city": "DADEVILLE",
            "state": "AL",
            "postal_code": "368536254",
            "telephone_number": "256-825-7050",
            "fax_number": "256-825-7068"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVY CREEK OF TALLAPOOSA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-07",
        "last_updated": "2022-04-05",
        "certification_date": "2022-04-05",
        "status": "A",
        "authorized_official_last_name": "TIDWELL",
        "authorized_official_first_name": "PAM",
        "authorized_official_title_or_position": "HOME HEALTH DIRECTOR",
        "authorized_official_telephone_number": "256-397-1440",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": "AL",
            "license": "017117",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "LAK7117A",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LAKE MARTIN HOME HEALTH",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dadeville, AL

Sources for this page

Verify at the official NPI Registry.