Provider Demographics
NPI:1093193849
Name:PREFERRED FAMILY HEALTHCARE
Entity Type:Organization
Organization Name:PREFERRED FAMILY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BONTIEA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-869-8911
Mailing Address - Street 1:1111 S GLENSTONE AVE
Mailing Address - Street 2:SUITE 3-100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-0338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:317 S MADISON AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-1568
Practice Address - Country:US
Practice Address - Phone:417-678-0123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCC01430115320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities