MEDICARE: CARLY CAMERON CAUDLE

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	225700000X	Massage Therapist	13650350-4701	UT

General Provider Information

NPI Number	:	1174397780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY CAMERON CAUDLE

Provider Business Mailing Address
First Line	:	1244 E BELLA VISTA DR
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037-2241
Country	:	US
Telephone Number	:	503-984-6147
Fax Number	:

Provider Business Practice Location Address
First Line	:	1244 E BELLA VISTA DR
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037-2241
Country	:	US
Telephone Number	:	503-984-6147
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2023
Last Update Date	:	11/14/2023

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Directions to “ CARLY CAMERON CAUDLE ” Practice Location

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