Provider Demographics
NPI:1184051567
Name:BACCHUS OPERATIONS GROUP, INC
Entity type:Organization
Organization Name:BACCHUS OPERATIONS GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:EASTMAN, III
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-904-6731
Mailing Address - Street 1:502 SUMTER ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-1734
Mailing Address - Country:US
Mailing Address - Phone:478-472-8178
Mailing Address - Fax:478-472-3289
Practice Address - Street 1:502 SUMTER ST
Practice Address - Street 2:SUITE B
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1734
Practice Address - Country:US
Practice Address - Phone:478-472-8178
Practice Address - Fax:478-472-3289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA094391261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care