Provider Demographics
NPI:1881635415
Name:BULLOCH HOME MEDICAL INC.
Entity Type:Organization
Organization Name:BULLOCH HOME MEDICAL INC.
Other - Org Name:GEORGIA HOME MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:FIVEASH
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:912-290-5063
Mailing Address - Street 1:P.O. BOX 702
Mailing Address - Street 2:
Mailing Address - City:CLAXTON
Mailing Address - State:GA
Mailing Address - Zip Code:30417-0702
Mailing Address - Country:US
Mailing Address - Phone:912-290-5063
Mailing Address - Fax:912-290-5066
Practice Address - Street 1:219 B. SOUTH DUVAL STREET
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-2031
Practice Address - Country:US
Practice Address - Phone:912-290-5063
Practice Address - Fax:912-290-5066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA199141282AMedicaid
GA5661800001Medicare NSC
5661800001Medicare NSC