Healthcare Provider Details

I. General information

NPI: 1558712034
Provider Name (Legal Business Name): CODAC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 N MAIN ST
PROVIDENCE RI
02904-5757
US

IV. Provider business mailing address

1052 PARK AVE
CRANSTON RI
02910-3225
US

V. Phone/Fax

Practice location:
  • Phone: 401-808-4278
  • Fax: 401-808-6957
Mailing address:
  • Phone: 401-275-5039
  • Fax: 401-942-3590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number605.07
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number605.07
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberACF01632
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number605.07
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number605.07
License Number StateRI
# 6
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number605.07
License Number StateRI

VIII. Authorized Official

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