Provider Demographics
NPI:1013696012
Name:K & M WELLNESS, INC
Entity Type:Organization
Organization Name:K & M WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LATREASE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:315-220-0603
Mailing Address - Street 1:#186 MOHAWK ACRES PLAZA
Mailing Address - Street 2:1756 BLACK RIVER BLVD
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440
Mailing Address - Country:US
Mailing Address - Phone:315-220-0603
Mailing Address - Fax:
Practice Address - Street 1:#186 MOHAWK ACRES PLAZA
Practice Address - Street 2:1756 BLACK RIVER BLVD
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-220-0603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health