| Name: | Ivy Creek Family Care of Lake Martin LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 23 Jan 2023 (2 years ago) |
| Entity Number: | 001-059-135 |
| Register Number: | 001059135 |
| County: | Tallapoosa |
| Place of Formation: | Alabama |
| Registered Office Street Address: | 201 Mariarden RoadDadeville, AL 36853 |
| Registered Office Street Address ZIP Code: | 36853 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1609572890 | 2023-01-31 | 2023-04-11 | PO BOX 130, WETUMPKA, AL, 360920003, US | 5958 HIGHWAY 49 S UNIT K, DADEVILLE, AL, 368536771, US | |||||||||||||||||||||
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| Phone | +1 334-514-3821 |
| Fax | 3345143686 |
| Phone | +1 256-825-7821 |
Authorized person
| Name | TERESA H LANGFORD |
| Role | CREDENTIALING MANAGER |
| Phone | 3347409109 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 261QU0200X - Urgent Care Clinic/Center |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| IVY CREEK HEALTHCARE, LLC | Agent | 16020 SW 80TH AVENUEMIAMI, FL 33157 |
Date of last update: 17 Aug 2024
Sources: Alabama Secretary of State
