MEDICARE: THE MILK GROTTO, 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	174N00000X	Lactation Consultant (Non-RN)

General Provider Information

NPI Number	:	1619432390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MILK GROTTO, LLC

Provider Business Mailing Address
First Line	:	PO BOX 161621
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78716-1621
Country	:	US
Telephone Number	:	512-651-9360
Fax Number	:

Provider Business Practice Location Address
First Line	:	10619 PLUCHEA CV
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78733-5721
Country	:	US
Telephone Number	:	512-551-2371
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KATINA WONG
Credential	:	IBCLC
Telephone Number	:	703-244-9216

Provider Enumeration Date	:	02/06/2019
Last Update Date	:	02/06/2019

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Directions to “THE MILK GROTTO, LLC ” Practice Location

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