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General NPI Number Information
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NPI Number | 1699037085
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Entity Type | Organization
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Legal Business Name | CAPITOL DIVERSIFIED SERVICES, LLC
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Dates
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Enumeration Date | 06/12/2012
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Last Update Date | 11/12/2014
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Provider Practice Location Address
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Address Line | 7724 EL DORADO DR
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City | AUSTIN
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State | TX
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Zip | 78737-3005
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Country | US
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Telephone | 512-767-0055
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Fax | 512-597-8824
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Provider Business Mailing Address
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Address Line | PO BOX 92944
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City | AUSTIN
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State | TX
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Zip | 78709-2944
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Country | US
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Telephone | 512-767-0055
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Fax | 512-597-8824
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Authorized Official
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Title or Position | CHIEF EXECUTIVE MEMBER
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Name | MR. RONALD D BENNETT
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Credential |
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Telephone | 512-767-0055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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