Healthcare Provider Details

I. General information

NPI: 1467988683
Provider Name (Legal Business Name): CODAC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1052 PARK AVE
CRANSTON RI
02910-3225
US

IV. Provider business mailing address

1052 PARK AVE
CRANSTON RI
02910-3225
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberACF01632
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberACF01632
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

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