Provider Demographics
NPI:1699188029
Name:PREFERRED FAMILY MEDICAL CARE LLC
Entity Type:Organization
Organization Name:PREFERRED FAMILY MEDICAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:423-665-3666
Mailing Address - Street 1:9026 HIWASSEE STREET NE
Mailing Address - Street 2:PO BOX 15
Mailing Address - City:CHARLESTON
Mailing Address - State:TN
Mailing Address - Zip Code:37310
Mailing Address - Country:US
Mailing Address - Phone:423-665-3666
Mailing Address - Fax:423-584-6747
Practice Address - Street 1:9026 HIWASSEE ST NE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:TN
Practice Address - Zip Code:37310-5305
Practice Address - Country:US
Practice Address - Phone:423-665-3666
Practice Address - Fax:423-584-6747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QS1200X, 261QU0200X
TN261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007277Medicaid