Provider Demographics
NPI:1760055719
Name:MOUNT KISCO WELLNESS FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:MOUNT KISCO WELLNESS FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KULRAVEE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUTTHARUSKA-KEEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-836-3892
Mailing Address - Street 1:PO BOX 64
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-0064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:666 LEXINGTON AVE STE 207A
Practice Address - Street 2:
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3635
Practice Address - Country:US
Practice Address - Phone:917-836-3892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty