Healthcare Provider Details

I. General information

NPI: 1043436785
Provider Name (Legal Business Name): CODAC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 THAMES ST CODAC NEWPORT
NEWPORT RI
02840
US

IV. Provider business mailing address

1052 PARK AVE
CRANSTON RI
02910
US

V. Phone/Fax

Practice location:
  • Phone: 401-846-4150
  • Fax: 401-846-9340
Mailing address:
  • Phone: 401-275-5038
  • Fax: 401-942-3590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number605.4
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number605.4
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberACF01632-05
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number605.4
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number605.04
License Number StateRI
# 6
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number605.4
License Number StateRI
# 7
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberACF01632-05
License Number StateRI
# 9
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number605.04
License Number StateRI

VIII. Authorized Official

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