Healthcare Provider Details

I. General information

NPI: 1235569328
Provider Name (Legal Business Name): CODAC HEALTH, RECOVERY & WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2013
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W ORANGE GROVE RD STE 416
TUCSON AZ
85704-1139
US

IV. Provider business mailing address

1650 E FORT LOWELL RD STE 202
TUCSON AZ
85719-2374
US

V. Phone/Fax

Practice location:
  • Phone: 520-327-4505
  • Fax: 520-202-1889
Mailing address:
  • Phone: 520-327-4505
  • Fax: 520-202-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberCSLG7120
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DENNIS REGNIER
Title or Position: CEO
Credential:
Phone: 520-327-4505