Provider Demographics
NPI:1467014753
Name:BRAZOSPORT PEDIATRIC AND FAMILY CLINIC PLLC
Entity Type:Organization
Organization Name:BRAZOSPORT PEDIATRIC AND FAMILY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:DEANN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-300-0032
Mailing Address - Street 1:222 N VELASCO ST STE A
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77515-4576
Mailing Address - Country:US
Mailing Address - Phone:979-300-0032
Mailing Address - Fax:979-297-9096
Practice Address - Street 1:222 N VELASCO ST STE A
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-4576
Practice Address - Country:US
Practice Address - Phone:979-300-0032
Practice Address - Fax:979-297-9096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-08
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1740052984OtherNPI
TX1457645806OtherNPI