Provider Demographics
NPI:1811906472
Name:CADDELL, KATHERINE L (ABOC)
Entity type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:L
Last Name:CADDELL
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:MRS
Other - First Name:LORI
Other - Middle Name:K
Other - Last Name:OROSCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:203 W. FOX ST.
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5736
Mailing Address - Country:US
Mailing Address - Phone:505-887-2919
Mailing Address - Fax:505-885-2713
Practice Address - Street 1:203 W. FOX ST.
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5736
Practice Address - Country:US
Practice Address - Phone:505-887-2919
Practice Address - Fax:505-885-2713
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM134655156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician