Provider Demographics
NPI:1467579490
Name:KMG HOLDINGS, INC.
Entity Type:Organization
Organization Name:KMG HOLDINGS, INC.
Other - Org Name:THE LIGHTHOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KORY
Authorized Official - Middle Name:
Authorized Official - Last Name:KALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-795-4438
Mailing Address - Street 1:PO BOX 24914
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27611
Mailing Address - Country:US
Mailing Address - Phone:919-795-4438
Mailing Address - Fax:919-882-6311
Practice Address - Street 1:10307 S. OAK ST.
Practice Address - Street 2:SUITE C
Practice Address - City:MIDDLESEX
Practice Address - State:NC
Practice Address - Zip Code:27557
Practice Address - Country:US
Practice Address - Phone:919-795-4438
Practice Address - Fax:919-882-6311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253J00000X
NCMHL-051114322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603214Medicaid