MEDICARE: CODAC 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	605.01	RI
2	276400000X	Substance Use Disorder Rehabilitation Hospital Unit	605.1	RI
3	261QP2300X	Primary Care Clinic/Center	ACF01632-01	RI
4	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	605.1	RI
5	175T00000X	Peer Specialist
6	207QA0401X	Addiction Medicine (Family Medicine) Physician	ACF01632-01	RI
7	251K00000X	Public Health or Welfare Agency	605.1	RI
8	261QM2800X	Methadone Clinic	605.01	RI

General Provider Information

NPI Number	:	1295731321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CODAC INC

Provider Business Mailing Address
First Line	:	1052 PARK AVE
Second Line	:
City	:	CRANSTON
State	:	RI
Zip	:	02910
Country	:	US
Telephone Number	:	401-275-5038
Fax Number	:	401-942-3590

Provider Business Practice Location Address
First Line	:	1052 PARK AVE
Second Line	:	CODAC CRANSTON
City	:	CRANSTON
State	:	RI
Zip	:	02910
Country	:	US
Telephone Number	:	401-461-5056
Fax Number	:	401-943-2167

Authorized Official
Title or Position	:	CFO
Name	:	MS. ALISHA M BOURDEAU
Credential	:	BS
Telephone Number	:	401-275-5038

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	12/21/2021

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Directions to “CODAC INC ” Practice Location

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