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103 W Frontage Rd Ste C Lucedale MS 39452-5836 | |
| (251) 633-0123 | |
| (251) 445-3722 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 103 W Frontage Rd Ste C, Lucedale, Mississippi |
| Authorized Official Name and Position | Bridgot Peters (BILLING DIRECTOR) |
| Authorized Official Contact | 2514457618 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
103 W Frontage Rd Ste C Lucedale MS 39452-5836 Ph: (601) 947-9596 | 103 W Frontage Rd Ste C Lucedale MS 39452-5836 Ph: (251) 633-0123 |
| NPI Number | 1700372034 |
|---|---|
| Provider Enumeration Date | 07/10/2018 |
| Last Update Date | 06/06/2023 |
| Medicare PECOS PAC ID | 0648528661 |
|---|---|
| Medicare Enrollment ID | O20180824001503 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1700372034 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
| 261QU0200X | Clinic/center - Urgent Care | (* (Not Available)) | Secondary |
| Provider Name | Hollis L Ward |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1154341774 PECOS PAC ID: 4688601354 Enrollment ID: I20120201000036 |
| Provider Name | Leigh A Havens |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1437477163 PECOS PAC ID: 8022149426 Enrollment ID: I20160810002289 |
| Provider Name | Jessica Gates |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1235653742 PECOS PAC ID: 8729352125 Enrollment ID: I20231023003154 |
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