Provider Demographics
NPI:1588609457
Name:BAINBRIDGE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:BAINBRIDGE HEALTHCARE, LLC
Other - Org Name:BAINBRIDGE HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYGH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-650-8773
Mailing Address - Street 1:1155 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-6400
Mailing Address - Country:US
Mailing Address - Phone:229-243-0931
Mailing Address - Fax:229-246-9284
Practice Address - Street 1:1155 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-6400
Practice Address - Country:US
Practice Address - Phone:229-243-0931
Practice Address - Fax:229-246-9284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-043-1835314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000258915AMedicaid
11-5324Medicare ID - Type UnspecifiedMUTUAL OF OMAHA