Provider Demographics
NPI:1558712034
Name:CODAC INC
Entity Type:Organization
Organization Name:CODAC INC
Other - Org Name:CODAC NORTH MAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:
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:02910-3225
Mailing Address - Country:US
Mailing Address - Phone:401-275-5039
Mailing Address - Fax:401-942-3590
Practice Address - Street 1:528 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5757
Practice Address - Country:US
Practice Address - Phone:401-808-4278
Practice Address - Fax:401-808-6957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
RI605.07251K00000X, 261QH0100X, 261QM2800X, 261QR0405X, 276400000X
RIACF01632261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or Welfare
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No276400000XHospital UnitsRehabilitation, Substance Use Disorder UnitGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RICI01382Medicaid