Healthcare Provider Details

I. General information

NPI: 1497308837
Provider Name (Legal Business Name): KGH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 BARBARA LOOP SE STE 107
RIO RANCHO NM
87124-1040
US

IV. Provider business mailing address

10230 GELFAND PL NW
ALBUQUERQUE NM
87114-4501
US

V. Phone/Fax

Practice location:
  • Phone: 513-370-0356
  • Fax:
Mailing address:
  • Phone: 513-370-0356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. KRISTAL KINZER HOWELL
Title or Position: REGISTERED AGENT
Credential: MA LPCC
Phone: 513-370-0356