Provider Demographics
NPI:1578070447
Name:CODAC HEALTH RECOVERY AND WELLNESS
Entity Type:Organization
Organization Name:CODAC HEALTH RECOVERY AND WELLNESS
Other - Org Name:CODAC AT ALVERNON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTS AND CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:AXINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-202-1755
Mailing Address - Street 1:1650 E FORT LOWELL RD STE 202
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2378
Mailing Address - Country:US
Mailing Address - Phone:520-327-4505
Mailing Address - Fax:520-202-1889
Practice Address - Street 1:630 N ALVERNON WAY STE 161
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1895
Practice Address - Country:US
Practice Address - Phone:520-318-9222
Practice Address - Fax:520-318-9094
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CODAC HEALTH RECOVERY AND WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health