Provider Demographics
NPI:1023044518
Name:BULLOCH COUNTY LTC LLC
Entity Type:Organization
Organization Name:BULLOCH COUNTY LTC LLC
Other - Org Name:EAGLE HEALTH AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-764-4575
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-0746
Mailing Address - Country:US
Mailing Address - Phone:912-764-4575
Mailing Address - Fax:912-764-3916
Practice Address - Street 1:405 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5409
Practice Address - Country:US
Practice Address - Phone:912-764-4575
Practice Address - Fax:912-764-3916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-016-1898314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000143151AMedicaid
GA000143151AMedicaid