MEDICARE: KRYSTALS HOUSE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	MHL 040-028	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336271691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRYSTALS HOUSE, LLC

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

Provider Business Practice Location Address
First Line	:	83 WHITE HORSE RD
Second Line	:
City	:	PIKEVILLE
State	:	NC
Zip	:	27863-8365
Country	:	US
Telephone Number	:	252-747-2988
Fax Number	:	252-747-4330

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. CAROLYN HODGES BRYANT
Credential	:
Telephone Number	:	252-315-4420

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	11/02/2016

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Directions to “KRYSTALS HOUSE, LLC ” Practice Location

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