NPIMap

Organization Active NPI

Ivy Creek of Elmore, LLC

  • Rural Health Clinic/Center
  • Deatsville, AL
National Provider Identifier
1578060349
Registry record updated Mar 20, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
IVY CREEK OF ELMORE, LLC
Practice address
4412 Hogan Rd
Deatsville, AL 36022-3400
Phone
(334) 514-4851
Fax
(334) 543-4854
NPI assigned
Apr 9, 2018
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Mrs. Jade Lane
Title
Credentialing Manager
Phone
(334) 567-4311

Owners & managing parties with NPI records 8

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

Owned or controlled facilities with NPI records 2

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

Other NPIs on the same Medicare enrollment 14

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

Other NPIs with the same Medicare PAC ID 6

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Facilities connected through Provider of Services related, parent or unit certification numbers.

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners 133

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 133

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
01D2153925Ivy Creek Family Care of Holtville4412 Hogan Road, Deatsville, AL 36022Certificate of waiverMay 11, 2027

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL2 enrollments

Rural health clinic certification: CCN 013474

Medicare enrollment files
Legal name
IVY CREEK OF ELMORE LLC
Doing business as
IVY CREEK FAMILY CARE OF HOLTVILLE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 31, 2018
Last certification
Dec 16, 2025
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Jun 30, 2000 in AL
Enrollment address
4412 Hogan Rd
Deatsville, AL 36022-3400
Related CCNs
010097

All disclosed owners & managing parties 6

Medicare enrollment files

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

NameRoleSinceShare
Amanda Hannon Individual Corporate OfficerCoo Aug 1, 2018 100%
Operational/Managerial ControlOperations Manager Aug 1, 2018 100%
Robert L England Individual 5% Or Greater Indirect Ownership InterestIndirect Owner Jul 1, 2012 24.5%
Seven Oaks Holdings Organization, Wetumpka, AL 5% Or Greater Direct Ownership Interest Jul 1, 2012 49%
Gerald a Sweeney Individual 5% Or Greater Indirect Ownership InterestIndirect Owner Jul 1, 2012 24.5%
Michael David Bruce Individual 5% Or Greater Direct Ownership InterestCeo Aug 1, 2018 100%
Ivy Creek of Elmore LLC Organization, Wetumpka, AL LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Aug 1, 2018 100%

All facility ownership & control disclosures 2

Medicare enrollment files

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

Medicare enrollment records 2

Medicare enrollment files
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
O20180726000966 AL Part a Provider - Rural Health Clinic 8426075508 Receives reassigned benefits from 1 practitioner
Practice locations: Deatsville, AL

National Provider Directory

National Provider Directory

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

NPPES NPI Registry

Primary practice location

4412 Hogan Rd
Deatsville, AL 36022-3400

Mailing address

PO Box 130
Wetumpka, AL 36092-0003
Phone (334) 514-4851

Other identifiers 4

NPPES NPI Registry
IdentifierTypeStateIssuer
1608OtherALMEDICARE B
01D2153925OtherALCLIA
231138MedicaidAL
13474OtherALMEDICARE A

Other names 1

NPPES NPI Registry
  • IVY CREEK FAMILY CARE OF HOLTVILLE Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Mar 20, 2025.

{
    "created_epoch": "1523232000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1742428800000",
    "number": "1578060349",
    "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": "334-514-4851",
            "fax_number": "334-543-4854"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4412 HOGAN RD",
            "city": "DEATSVILLE",
            "state": "AL",
            "postal_code": "360223400",
            "telephone_number": "334-514-4851",
            "fax_number": "334-543-4854"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVY CREEK OF ELMORE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-04-09",
        "last_updated": "2025-03-20",
        "certification_date": "2025-03-20",
        "status": "A",
        "authorized_official_last_name": "LANE",
        "authorized_official_first_name": "JADE",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "334-567-4311",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE   B",
            "identifier": "1608",
            "state": "AL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA",
            "identifier": "01D2153925",
            "state": "AL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "231138",
            "state": "AL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE    A",
            "identifier": "13474",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "IVY CREEK FAMILY CARE OF HOLTVILLE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Deatsville, AL

Sources for this page

Verify at the official NPI Registry.