Healthcare Provider Details

I. General information

NPI: 1164923553
Provider Name (Legal Business Name): CODAC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 REGAN CT
CRANSTON RI
02920
US

IV. Provider business mailing address

1052 PARK AVE
CRANSTON RI
02910-3225
US

V. Phone/Fax

Practice location:
  • Phone: 401-462-3530
  • Fax: 401-462-3529
Mailing address:
  • Phone: 401-275-5038
  • Fax: 401-942-3590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number605.08
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number605.08
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number605.08
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALISHA M BOURDEAU
Title or Position: CFO
Credential:
Phone: 401-275-5038