MEDICARE: CAPITAL DISTRICT RESPITE, INC.

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	385HR2055X	Child Mental Illness Respite Care

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790177061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITAL DISTRICT RESPITE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 111
Second Line	:
City	:	BALLSTON SPA
State	:	NY
Zip	:	12020-0111
Country	:	US
Telephone Number	:	518-527-6531
Fax Number	:	518-373-2901

Provider Business Practice Location Address
First Line	:	199 MILTON AVE STE 11
Second Line	:
City	:	BALLSTON SPA
State	:	NY
Zip	:	12020-1454
Country	:	US
Telephone Number	:	518-527-6531
Fax Number	:	518-373-2901

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. PAULA A. TAMBASCO
Credential	:
Telephone Number	:	518-527-6531

Provider Enumeration Date	:	02/24/2015
Last Update Date	:	02/24/2015

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