Provider Demographics
NPI:1679792162
Name:CAUDILL BOUTIN THERAPEUTICS
Entity type:Organization
Organization Name:CAUDILL BOUTIN THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:502-425-3611
Mailing Address - Street 1:7410 NEW LAGRANGE RD
Mailing Address - Street 2:#302
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4871
Mailing Address - Country:US
Mailing Address - Phone:502-425-3611
Mailing Address - Fax:502-426-0336
Practice Address - Street 1:7410 NEW LAGRANGE RD
Practice Address - Street 2:#302
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4871
Practice Address - Country:US
Practice Address - Phone:502-425-3611
Practice Address - Fax:502-426-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0782174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty