=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104083435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINDHAVEN ADOLESCENT MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2008
-----------------------------------------------------
Last Update Date | 05/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6300 W PARKER RD SUITE 324
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-8100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-403-5437
-----------------------------------------------------
Fax | 972-403-5438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6300 W PARKER RD SUITE 324
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-8100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-403-5437
-----------------------------------------------------
Fax | 972-403-5438
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAURA SCALFANO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 972-403-5437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | K1659
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------