NPIMap

Organization Active NPI

Lake Martin Hospice LLC.

Doing business as Ivy Creek Hospice

  • Community Based Hospice Care Agency
  • Dadeville, AL
National Provider Identifier
1346305216
Registry record updated Mar 29, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
Legal business name
LAKE MARTIN HOSPICE LLC.
Doing business as
Ivy Creek Hospice
Practice address
201 Mariarden Rd
Dadeville, AL 36853-6244
Phone
(256) 825-3272
Fax
(256) 825-8578
NPI assigned
Dec 22, 2006
Last updated
Mar 29, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 29, 2018

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

Authorized official

Name
Michael D Bruce
Title
Ceo
Phone
(256) 825-4785

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X Primary

Addresses

Primary practice location

201 Mariarden Rd
Dadeville, AL 36853-6244

Mailing address

201 Mariarden Rd
Dadeville, AL 36853-6244
Phone (256) 825-3272

Other practice location 1

500 Hospital Dr
Wetumpka, AL 36092-1625
Phone (334) 514-0682

Other identifiers 1

IdentifierTypeStateIssuer
PIC1621EMedicaidAL

Other names 1

  • IVY CREEK HOSPICE Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180530000936 AL Part A Provider - Hospice 7911262696 Practice locations: Dadeville, AL; Wetumpka, AL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1346305216. Details of each certification follow.

Hospice certification: CCN 011621

Legal name
LAKE MARTIN HOSPICE LLC.
Doing business as
IVY CREEK HOSPICE
Certification status
Active
Provider type (POS)
Hospice
Participating since
Nov 2, 2004
Last certification
Apr 22, 2021
Ownership / control type
Proprietary - Corporation
Organization structure
LLCProprietary
Incorporated
Jul 10, 2014 in AL
Enrollment address
201 Mariarden Rd
Dadeville, AL 36853-6244

Care Compare: Hospice

Medicare Care Compare
Listed as
Ivy Creek HospiceCCN 011621 · All quality measures
Ownership
For-Profit
Certified
Nov 2, 2004
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
Stephanie Weatherly Individual W-2 Managing EmployeeBranch Manager Oct 1, 2023 50%
Melissa D Thompson Individual Contracted Managing EmployeeHospice Medical Director Nov 1, 2023 100%
Linda Segrest Individual W-2 Managing EmployeeExecutive Director Apr 1, 2018 100%
Ivy Creek Healthcare LLC Organization, Palmetto Bay, FL LLC 5% Or Greater Indirect Ownership Interest Jun 30, 2001 100%
Michael David Bruce Individual 5% Or Greater Direct Ownership InterestCeo Apr 1, 2018 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Change-of-ownership history 1

DateEventCounterparty
Apr 1, 2018 Change of OwnershipThis provider was the buyer Lake Martin HospiceCCN 011621, AL, NPI 1598783904

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Practitioners & affiliated clinicians

Affiliated clinicians 9

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": "1166745600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1522281600000",
    "number": "1346305216",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "201 MARIARDEN RD",
            "city": "DADEVILLE",
            "state": "AL",
            "postal_code": "368536244",
            "telephone_number": "256-825-3272",
            "fax_number": "256-825-8578"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 MARIARDEN RD",
            "city": "DADEVILLE",
            "state": "AL",
            "postal_code": "368536244",
            "telephone_number": "256-825-3272",
            "fax_number": "256-825-8578"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "500 Hospital Dr",
            "address_purpose": "LOCATION",
            "city": "Wetumpka",
            "state": "AL",
            "postal_code": "360921625",
            "country_code": "US",
            "telephone_number": "334-514-0682",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "LAKE MARTIN HOSPICE LLC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-22",
        "last_updated": "2018-03-29",
        "status": "A",
        "authorized_official_last_name": "BRUCE",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "256-825-4785"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "PIC1621E",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "IVY CREEK HOSPICE",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "IVY CREEK HOSPICE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dadeville, AL

Sources for this page

Verify at the official NPI Registry.