Provider Demographics
NPI:1255820007
Name:BACCHUS PRIVATE HOME CARE LLC
Entity type:Organization
Organization Name:BACCHUS PRIVATE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BACCHUS-LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-468-7130
Mailing Address - Street 1:4925 BRIDLE POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-3343
Mailing Address - Country:US
Mailing Address - Phone:404-468-7130
Mailing Address - Fax:770-679-0617
Practice Address - Street 1:4925 BRIDLE POINT PARKWAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039
Practice Address - Country:US
Practice Address - Phone:404-468-7130
Practice Address - Fax:770-679-0617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-1438251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health