NPIMap

Organization Active NPI

Ivy Creek of Elmore, LLC

Doing business as Reference Lab

  • Clinical Medical Laboratory
  • Wetumpka, AL
National Provider Identifier
1265027908
Registry record updated Jun 15, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Medical LaboratoryTaxonomy code 291U00000X
Legal business name
IVY CREEK OF ELMORE, LLC
Doing business as
Reference Lab
Practice address
500 Hospital Dr
Wetumpka, AL 36092-1625
Phone
(334) 567-4311
Fax
(334) 514-3686
NPI assigned
Mar 4, 2021
Last updated
Jun 15, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
IVY CREEK OF ELMORE, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 15, 2021

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

Authorized official

Name
Michael D Bruce, CEO
Title
Ceo & Ao
Phone
(334) 567-4311

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Medical Laboratory 291U00000X NU Primary

Addresses

Primary practice location

500 Hospital Dr
Wetumpka, AL 36092-1625

Mailing address

PO Box 130
Wetumpka, AL 36092-0003
Phone (334) 567-4311

Other names 1

  • REFERENCE LAB Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
RESTful URL DIRECT IVY CREEK OF ELMORE, LLC

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210713000083 AL Part B Supplier - Independent Clinical Laboratory 8426075508 Practice locations: Wetumpka, AL

Other NPIs with the same Medicare PAC ID 6

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
01D0680545Elmore Community Hospital Laboratory500 Hospital Drive, Wetumpka, AL 36092AccreditationSep 3, 2027

National Provider Directory

National Provider Directory
Tax ID family
Marcial Mendrz MD8 organizations share this tax ID, including this one
Part of
Marcial Mendrz MD

Other organizations with this tax ID 7

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

Ownership & related parties

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Elmore Community HospitalWetumpka, AL, CCN 010097 Hospital 5% Or Greater Direct Ownership Interest (100%) Jun 30, 2000
Wetumpka Family Rural Health ClinicWetumpka, AL, CCN 013960 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Jun 30, 2000
Ivy Creek Family Care of HoltvilleDeatsville, AL, CCN 013474 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Aug 1, 2018

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

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

{
    "created_epoch": "1614816000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623715200000",
    "number": "1265027908",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 130",
            "city": "WETUMPKA",
            "state": "AL",
            "postal_code": "360920003",
            "telephone_number": "334-567-4311",
            "fax_number": "334-514-3686"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 HOSPITAL DR",
            "city": "WETUMPKA",
            "state": "AL",
            "postal_code": "360921625",
            "telephone_number": "334-567-4311",
            "fax_number": "334-514-3686"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVY CREEK OF ELMORE, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "IVY CREEK OF ELMORE, LLC",
        "enumeration_date": "2021-03-04",
        "last_updated": "2021-06-15",
        "certification_date": "2021-06-15",
        "status": "A",
        "authorized_official_last_name": "BRUCE",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "CEO & AO",
        "authorized_official_telephone_number": "334-567-4311",
        "authorized_official_credential": "CEO"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "REST",
            "endpointTypeDescription": "RESTful URL",
            "endpoint": "DIRECT",
            "affiliation": "Y",
            "affiliationName": "IVY CREEK OF ELMORE, LLC",
            "address_1": "500 Hospital Dr",
            "city": "Wetumpka",
            "state": "AL",
            "country_code": "US",
            "postal_code": "360921625",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "REFERENCE LAB",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wetumpka, AL

Sources for this page

Verify at the official NPI Registry.