Provider Demographics
NPI:1104914480
Name:BACCHUS OPERATIONS GROUP, INC.
Entity type:Organization
Organization Name:BACCHUS OPERATIONS GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-472-3100
Mailing Address - Street 1:509 SUMTER ST
Mailing Address - Street 2:P.O. BOX 770 (31063-2502)
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:478-472-3248
Practice Address - Street 1:502 SUMTER ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1734
Practice Address - Country:US
Practice Address - Phone:478-472-8178
Practice Address - Fax:478-472-3289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00014987CMedicaid
GA00014987CMedicaid