Provider Demographics
NPI:1962573170
Name:PRIMESOURCE NURSING SERVICES, INC
Entity type:Organization
Organization Name:PRIMESOURCE NURSING SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHETT
Authorized Official - Middle Name:M
Authorized Official - Last Name:PLAUCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-865-1330
Mailing Address - Street 1:PO BOX 6705
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6705
Mailing Address - Country:US
Mailing Address - Phone:228-865-1330
Mailing Address - Fax:228-865-1331
Practice Address - Street 1:370 COURTHOUSE RD STE 106
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1889
Practice Address - Country:US
Practice Address - Phone:228-865-1330
Practice Address - Fax:228-865-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MS7381363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06550237Medicaid
MS=========OtherBCBS OF MISSISSIPPI
MSC03292Medicare PIN