Healthcare Provider Details

I. General information

NPI: 1679792162
Provider Name (Legal Business Name): CAUDILL BOUTIN THERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7410 NEW LAGRANGE RD #302
LOUISVILLE KY
40222-4871
US

IV. Provider business mailing address

7410 NEW LAGRANGE RD #302
LOUISVILLE KY
40222-4871
US

V. Phone/Fax

Practice location:
  • Phone: 502-425-3611
  • Fax: 502-426-0336
Mailing address:
  • Phone: 502-425-3611
  • Fax: 502-426-0336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0782
License Number StateKY

VIII. Authorized Official

Name: MS. TAMARA D CAUDILL
Title or Position: OWNER
Credential: LMT
Phone: 502-425-3611