Healthcare Provider Details

I. General information

NPI: 1174841456
Provider Name (Legal Business Name): BEANSPROUT PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13917 W HIGHWAY 71 STE A
AUSTIN TX
78738-3008
US

IV. Provider business mailing address

13917 W HIGHWAY 71 STE A
AUSTIN TX
78738-3008
US

V. Phone/Fax

Practice location:
  • Phone: 512-610-7030
  • Fax: 512-610-7034
Mailing address:
  • Phone: 512-610-7030
  • Fax: 512-610-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DANIELLE DENISE GRANT
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 512-610-7030