Provider Demographics
NPI:1396581872
Name:CHAMPION CAUDILL, HAILEY L
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:L
Last Name:CHAMPION CAUDILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FORTRESS PROPERTIES ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-3144
Mailing Address - Country:US
Mailing Address - Phone:606-877-1877
Mailing Address - Fax:
Practice Address - Street 1:100 FORTRESS PROPERTIES ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-3144
Practice Address - Country:US
Practice Address - Phone:606-877-1877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2390DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist