MEDICARE: KIND COMPASSIONATE RELIEF KCR

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1255053971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIND COMPASSIONATE RELIEF KCR

Provider Business Mailing Address
First Line	:	925 SULLIVAN AVE STE 2
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-2080
Country	:	US
Telephone Number	:	201-982-3828
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 SULLIVAN AVE STE 2
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-2080
Country	:	US
Telephone Number	:	201-982-3828
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	KHUSHBOO SURTI
Credential	:	APRN
Telephone Number	:	201-982-3828

Provider Enumeration Date	:	09/19/2022
Last Update Date	:	05/02/2023

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