MEDICARE: CODAC HEALTH, RECOVERY & WELLNESS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center	BH-3922	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952685414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CODAC HEALTH, RECOVERY & WELLNESS, INC.

Provider Business Mailing Address
First Line	:	1650 E FORT LOWELL RD
Second Line	:	SUITE 202
City	:	TUCSON
State	:	AZ
Zip	:	85719-2374
Country	:	US
Telephone Number	:	520-327-4505
Fax Number	:	520-202-1889

Provider Business Practice Location Address
First Line	:	1080 S 10TH AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85701-2907
Country	:	US
Telephone Number	:	520-623-3533
Fax Number	:	520-594-6345

Authorized Official
Title or Position	:	CEO
Name	:	MR. DENNIS REGNIER
Credential	:
Telephone Number	:	520-327-4505

Provider Enumeration Date	:	10/03/2011
Last Update Date	:	09/25/2015

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