Provider Demographics
NPI:1952190290
Name:SPROUTED BEAN PEDIATRICS AND WELLNESS LLC
Entity type:Organization
Organization Name:SPROUTED BEAN PEDIATRICS AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:FOULKS-THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CPM, LM, IBCLC
Authorized Official - Phone:612-237-2746
Mailing Address - Street 1:W233N7735 CHESTNUT CT
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-1522
Mailing Address - Country:US
Mailing Address - Phone:612-237-2746
Mailing Address - Fax:
Practice Address - Street 1:N63W23675 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-3977
Practice Address - Country:US
Practice Address - Phone:612-237-2746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-03
Last Update Date:2025-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health