Provider Demographics
NPI:1104871094
Name:NINE PALMS 2 LLC
Entity type:Organization
Organization Name:NINE PALMS 2 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSSEROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-292-2031
Mailing Address - Street 1:3854 AMERICAN WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4013
Mailing Address - Country:US
Mailing Address - Phone:225-292-2031
Mailing Address - Fax:225-295-9678
Practice Address - Street 1:11010 HIGHWAY 49
Practice Address - Street 2:STE 4
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4190
Practice Address - Country:US
Practice Address - Phone:228-831-9821
Practice Address - Fax:228-831-9826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12384251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000070508OtherBC BS OF MS FED
MS000070507OtherBC BS OF MS
MS00770616Medicaid
MS000070508OtherBC BS OF MS
MS000070507OtherADVANCED HEALTH SYSTEMS
MS000070508OtherADVANCED HEALTH SYSTEMS
MS000070508OtherBC BS OF MS
MS=========OtherVITAL CARE
MS00770616Medicaid
MS000070508OtherADVANCED HEALTH SYSTEMS
MS=========OtherCIGNA
MS000070507OtherBC BS OF MS
MS=========OtherUNITED HEALTHCARE
MS=========OtherMS PHYSICIANS CARE NETWK
MS00770616Medicaid