Provider Demographics
NPI:1104553494
Name:WILDFLOWER BREAST CENTER, PLLC
Entity type:Organization
Organization Name:WILDFLOWER BREAST CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANGEETHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOLLURI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:512-862-1881
Mailing Address - Street 1:2121 LOHMANS CROSSING RD STE 504714
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734-5217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4613 BEE CAVES RD # A120
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-5203
Practice Address - Country:US
Practice Address - Phone:512-862-1881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-05
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty