Provider Demographics
NPI:1497640007
Name:KRYSTAL'S HOUSE, INC
Entity type:Organization
Organization Name:KRYSTAL'S HOUSE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:877-213-3533
Mailing Address - Street 1:1700 E ASH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-4097
Mailing Address - Country:US
Mailing Address - Phone:877-213-3533
Mailing Address - Fax:877-213-3533
Practice Address - Street 1:83 WHITE HORSE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:PIKEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27863
Practice Address - Country:US
Practice Address - Phone:919-709-0009
Practice Address - Fax:877-213-7622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No253Z00000XAgenciesIn Home Supportive Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1578856266Medicaid