Basic Information
| Provider Information | |||||||||
| NPI: | 1982082624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREFERRED FAMILY HEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| 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: | 6910 N HOLMES ST | ||||||||
| Address2: | SUITE 231 | ||||||||
| City: | GLADSTONE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641182614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163532750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONOVER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF REVENUE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5736031460 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | CC01430115 | MO | Y | Agencies | Day Training, Developmentally Disabled Services |
No ID Information.