Basic Information
Provider Information | |||||||||
NPI: | 1639592256 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREFERRED FAMILY HEALTHCARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLARITY HEALTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1601 OLD SOUTH RIVER RD | ||||||||
Address2: |   | ||||||||
City: | SAINT CHARLES | ||||||||
State: | MO | ||||||||
PostalCode: | 633034120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362241210 | ||||||||
FaxNumber: | 6362461008 | ||||||||
Practice Location | |||||||||
Address1: | 141 COMMUNICATION DR | ||||||||
Address2: |   | ||||||||
City: | HANNIBAL | ||||||||
State: | MO | ||||||||
PostalCode: | 634013670 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5737957342 | ||||||||
FaxNumber: | 5732483080 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/03/2014 | ||||||||
LastUpdateDate: | 07/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONOVER | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF REVENUE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6606651962 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PREFERRED FAMILY HEALTHCARE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261QD0000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QP2300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QF0400X |   | MO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1639592256 | 05 | MO |   | MEDICAID |