| Organization Name: | BACCHUS OPERATIONS GROUP, INC |
| NPI Number: | 1184051567 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | PHILIP H EASTMAN, III (CEO) |
| Mailing Address: | 502 Sumter St Suite B Montezuma |
| State: | GA US |
| Postal Code: | 310631734 |
| Phone Number: | 4784728178 |
| Fax Number: | 4784723289 |
| NPI Enumeration Date: | 10/01/2013 |
| NPI Last Update Date: | 10/01/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QU0200X |
| License Number: | 094391 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Urgent Care |
| Taxonomy Definition: | |