Provider Demographics
NPI:1568823086
Name:KD SUPPORT SERVICES
Entity Type:Organization
Organization Name:KD SUPPORT SERVICES
Other - Org Name:KELLYS CARE 8
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DELLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:BS;QP
Authorized Official - Phone:828-245-4011
Mailing Address - Street 1:158 US HIGHWAY 221A
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043-5600
Mailing Address - Country:US
Mailing Address - Phone:828-245-4011
Mailing Address - Fax:828-245-4099
Practice Address - Street 1:1366 COOPERS GAP RD
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-8661
Practice Address - Country:US
Practice Address - Phone:828-286-4044
Practice Address - Fax:828-245-4099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-081-091320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418462Medicaid