Provider Demographics
NPI:1336271691
Name:KRYSTALS HOUSE, LLC
Entity Type:Organization
Organization Name:KRYSTALS HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:HODGES
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-315-4420
Mailing Address - Street 1:83 WHITE HORSE RD
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27863-8365
Mailing Address - Country:US
Mailing Address - Phone:252-747-2988
Mailing Address - Fax:252-747-2988
Practice Address - Street 1:83 WHITE HORSE RD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27863-8365
Practice Address - Country:US
Practice Address - Phone:252-747-2988
Practice Address - Fax:252-747-4330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 040-028311ZA0620X
NCMHL -040-028320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care HomeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805534Medicaid
NC7805534Medicaid
NC6008804Medicaid
NC8301565SMedicaid