1336271691 NPI number — KRYSTALS HOUSE, LLC

Table of content: (NPI 1336271691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336271691 NPI number — KRYSTALS HOUSE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRYSTALS HOUSE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336271691
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
83 WHITE HORSE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIKEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27863-8365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-747-2988
Provider Business Mailing Address Fax Number:
252-747-2988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
83 WHITE HORSE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27863-8365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-747-2988
Provider Business Practice Location Address Fax Number:
252-747-4330
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRYANT
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
HODGES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
252-315-4420

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  MHL 040-028 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7805534 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com