Healthcare Provider Details

I. General information

NPI: 1225611528
Provider Name (Legal Business Name): PREFERRED PHP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 RIDGEWOOD PL FL 2
JACKSON MS
39211-2018
US

IV. Provider business mailing address

PO BOX 13531
JACKSON MS
39236-3531
US

V. Phone/Fax

Practice location:
  • Phone: 601-957-3211
  • Fax: 601-957-9753
Mailing address:
  • Phone: 601-957-3211
  • Fax: 601-957-9753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: KRISHAN K GUPTA
Title or Position: CEO
Credential: MD
Phone: 601-957-3211