Healthcare Provider Details

I. General information

NPI: 1306828553
Provider Name (Legal Business Name): ALICE CAUDILL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 GORMAN HOLLOW RD
HAZARD KY
41701-2315
US

IV. Provider business mailing address

441 GORMAN HOLLOW RD
HAZARD KY
41701-2315
US

V. Phone/Fax

Practice location:
  • Phone: 606-439-2361
  • Fax: 606-439-0870
Mailing address:
  • Phone: 606-439-2361
  • Fax: 606-439-0870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberKY-0547
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: