=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336397678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMERLIN HEALTH & WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2008
-----------------------------------------------------
Last Update Date | 08/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10050 BANBURRY CROSS DR SUITE 130
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89144-7056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-360-4836
-----------------------------------------------------
Fax | 702-946-0866
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10050 BANBURRY CROSS DR SUITE 130
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89144-7056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-360-4836
-----------------------------------------------------
Fax | 702-946-0866
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DR. MICHELE ALISA DILAURO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 702-360-4836
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4910-C
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 10917
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------