Provider Demographics
NPI:1376769919
Name:CODAC INC
Entity Type:Organization
Organization Name:CODAC INC
Other - Org Name:CODAC EAST BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOURDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:401-275-5038
Mailing Address - Street 1:1052 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910
Mailing Address - Country:US
Mailing Address - Phone:401-275-5038
Mailing Address - Fax:401-942-3590
Practice Address - Street 1:850 WATERMAN AVE
Practice Address - Street 2:CODAC EAST BAY
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914
Practice Address - Country:US
Practice Address - Phone:401-434-4999
Practice Address - Fax:401-434-6116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
RIACF01632-03207QA0401X, 261QP2300X
RI605.2251K00000X, 261QM2800X, 261QR0405X, 276400000X
RI605.02261QM2800X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or WelfareGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No276400000XHospital UnitsRehabilitation, Substance Use Disorder UnitGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RICE16533Medicaid