MEDICARE: BAYLOR CAVALCADE TEEN HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336S0011X	Specialty Pharmacy	16507	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2155708	OTHER		PK

General Provider Information

NPI Number	:	1114392966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYLOR CAVALCADE TEEN HEALTH

Provider Business Mailing Address
First Line	:	1504 TAUB LOOP BLDG 1A29
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1608
Country	:	US
Telephone Number	:	713-440-7313
Fax Number	:

Provider Business Practice Location Address
First Line	:	3815 CAVALCADE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77026-3403
Country	:	US
Telephone Number	:	713-673-1655
Fax Number	:	713-440-9238

Authorized Official
Title or Position	:	R.N.
Name	:	CAROLINA SALAZAR
Credential	:
Telephone Number	:	713-440-7313

Provider Enumeration Date	:	12/04/2015
Last Update Date	:	12/04/2015

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