Healthcare Provider Details

I. General information

NPI: 1952884652
Provider Name (Legal Business Name): PRIMESOURCE NURSING SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 BROAD AVE
GULFPORT MS
39501-3601
US

IV. Provider business mailing address

PO BOX 6705
GULFPORT MS
39506-6705
US

V. Phone/Fax

Practice location:
  • Phone: 228-865-1330
  • Fax: 228-865-1331
Mailing address:
  • Phone: 228-865-1330
  • Fax: 228-865-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RHETT PLAUCHE
Title or Position: PRESIDENT
Credential:
Phone: 228-865-1330