Healthcare Provider Details

I. General information

NPI: 1710365564
Provider Name (Legal Business Name): PREFERRED FAMILY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7020 CHIPPEWA ST
SAINT LOUIS MO
63119-5602
US

IV. Provider business mailing address

1601 OLD SOUTH RIVER RD
SAINT CHARLES MO
63303-4120
US

V. Phone/Fax

Practice location:
  • Phone: 314-835-0226
  • Fax:
Mailing address:
  • Phone: 636-224-1210
  • Fax: 636-246-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberCC01430115
License Number StateMO

VIII. Authorized Official

Name: MARK CONOVER
Title or Position: CHIEF REVENUE OFFICER
Credential:
Phone: 573-603-1460