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General NPI Number Information
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NPI Number | 1679792162
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Entity Type | Organization
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Legal Business Name | CAUDILL BOUTIN THERAPEUTICS
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7410 NEW LAGRANGE RD #302
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City | LOUISVILLE
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State | KY
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Zip | 40222-4871
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Country | US
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Telephone | 502-425-3611
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Fax | 502-426-0336
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Provider Business Mailing Address
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Address Line | 7410 NEW LAGRANGE RD #302
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City | LOUISVILLE
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State | KY
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Zip | 40222-4871
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Country | US
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Telephone | 502-425-3611
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Fax | 502-426-0336
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Authorized Official
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Title or Position | OWNER
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Name | MS. TAMARA D CAUDILL
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Credential | LMT
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Telephone | 502-425-3611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0782
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License Number State | KY
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