Basic Information
Provider Information | |||||||||
NPI: | 1821411307 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREFERRED FAMILY HEALTHCARE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PREFERRED FAMILY HEALTHCARE, INC. | ||||||||
OtherOrganizationType: | 5 | ||||||||
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: | 900 E LAHARPE ST | ||||||||
Address2: |   | ||||||||
City: | KIRKSVILLE | ||||||||
State: | MO | ||||||||
PostalCode: | 635014520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6606651962 | ||||||||
FaxNumber: | 6606653989 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/04/2014 | ||||||||
LastUpdateDate: | 07/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONOVER | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF REVENUE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5736031460 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PREFERRED FAMILY HEALTHCARE, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.