Provider Demographics
NPI:1154454833
Name:MOTHERS' MILK BANK AT AUSTIN
Entity Type:Organization
Organization Name:MOTHERS' MILK BANK AT AUSTIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:UPDEGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, MPH, MSN
Authorized Official - Phone:512-494-0800
Mailing Address - Street 1:5925 DILLARD CIRCLE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752
Mailing Address - Country:US
Mailing Address - Phone:512-494-0800
Mailing Address - Fax:512-494-0880
Practice Address - Street 1:5925 DILLARD CIRCLE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752
Practice Address - Country:US
Practice Address - Phone:512-494-0800
Practice Address - Fax:512-494-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty
No251V00000XAgenciesVoluntary or CharitableGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0057887-01Medicaid