Provider Demographics
NPI:1518026202
Name:BACCHUS OPERATIONS GROUP, INC.
Entity Type:Organization
Organization Name:BACCHUS OPERATIONS GROUP, INC.
Other - Org Name:FLINT RIVER RURAL HEALTH CLINIC - ELLAVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:EASTMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:478-472-3100
Mailing Address - Street 1:509 SUMTER STREET
Mailing Address - Street 2:PO BOX 770
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-1733
Mailing Address - Country:US
Mailing Address - Phone:478-472-3100
Mailing Address - Fax:478-472-2412
Practice Address - Street 1:509 SUMTER STREET
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1733
Practice Address - Country:US
Practice Address - Phone:478-472-3100
Practice Address - Fax:478-472-2412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA094-391261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000149487BMedicaid
GA113404Medicare ID - Type UnspecifiedPROVIDER NUMBER