NPIMap

Organization Active NPI

Ivy Creek of Tallapoosa LLC

Doing business as Lake Martin Family Medicine

  • Rural Health Clinic/Center
  • Dadeville, AL
National Provider Identifier
1932130002
Registry record updated Apr 5, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
IVY CREEK OF TALLAPOOSA LLC
Doing business as
Lake Martin Family Medicine
Practice address
301 Mariarden Rd
Dadeville, AL 36853-0129
Phone
(256) 825-7871
Fax
(256) 825-5742
NPI assigned
Jul 6, 2006
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
Michael D Bruce
Title
Ceo
Phone
(334) 567-4311

Specialties & licenses 1

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

Addresses

Primary practice location

301 Mariarden Rd
Dadeville, AL 36853-0129

Mailing address

PO Box 129
Dadeville, AL 36853-0129
Phone (256) 825-7871

Other names 1

  • Lake Martin Family Medicine Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031229000288 AL Part B Supplier - Clinic/Group Practice 8123938719 Receives reassigned benefits from 43 practitioners
1 other NPI on this enrollment
Practice locations: Dadeville, AL
O20080627000251 AL Part A Provider - Rural Health Clinic 8123938719 Practice locations: Dadeville, AL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1932130002. Details of each certification follow.

Rural health clinic certification: CCN 013420

Legal name
IVY CREEK OF TALLAPOOSA LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Oct 7, 1996
Last certification
Jun 8, 2023
Ownership / control type
1A
Organization structure
LLCProprietary
Incorporated
Jul 1, 2001 in AL
Enrollment address
301 Mariarden Rd
Ste D
Dadeville, AL 36853-6245
Related CCNs
010052

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

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 1

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

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
01D0920584Lake Martin Family Medicine301 Mariarden Road, Dadeville, AL 36853Certificate of waiverOct 3, 2026

National Provider Directory

National Provider Directory
Tax ID family
Ivy Creek of Tallapoosa LLC8 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.

Locations

301 Mariarden Rd
Ste B
Dadeville, AL 36853
Phone (256) 825-7164

301 Mariarden Rd
Ste D
Dadeville, AL 36853
Phone (256) 825-7871

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Patricia W Bunn Individual Corporate Director Jul 1, 2008
W-2 Managing Employee Jul 1, 2008
Michael David Bruce Individual 5% Or Greater Direct Ownership InterestOwner Jul 1, 2001
Recie Mann Individual Corporate Director Oct 14, 2022
W-2 Managing EmployeePractice Manager Oct 14, 2022

Practitioners & affiliated clinicians

Practitioners 44

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.

View all 44

NPI Registry JSON

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

{
    "created_epoch": "1152144000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1649116800000",
    "number": "1932130002",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 129",
            "city": "DADEVILLE",
            "state": "AL",
            "postal_code": "368530129",
            "telephone_number": "256-825-7871",
            "fax_number": "256-825-5742"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "301 MARIARDEN RD",
            "city": "DADEVILLE",
            "state": "AL",
            "postal_code": "368530129",
            "telephone_number": "256-825-7871",
            "fax_number": "256-825-5742"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVY CREEK OF TALLAPOOSA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-06",
        "last_updated": "2022-04-05",
        "certification_date": "2022-04-05",
        "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": "334-567-4311"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Martin Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Lake Martin Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dadeville, AL

Sources for this page

Verify at the official NPI Registry.