Healthcare Provider Details

I. General information

NPI: 1356374953
Provider Name (Legal Business Name): CODAC BEHAVIORAL HEALTH SERVICES OF PIMA COUNTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1671 W GRANT RD
TUCSON AZ
85745-1433
US

IV. Provider business mailing address

127 S 5TH AVE
TUCSON AZ
85701-2005
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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberBH-2016
License Number StateAZ

VIII. Authorized Official

Name: MR. W. MARK CLARK
Title or Position: CEO
Credential:
Phone: 520-327-4505