Provider Demographics
NPI:1699226068
Name:CODAC HEALTH, RECOVERY & WELLNESS, INC.
Entity Type:Organization
Organization Name:CODAC HEALTH, RECOVERY & WELLNESS, INC.
Other - Org Name:GILA HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:REGNIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-4505
Mailing Address - Street 1:1650 E FORT LOWELL RD
Mailing Address - Street 2:STE 202
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2374
Mailing Address - Country:US
Mailing Address - Phone:520-327-4505
Mailing Address - Fax:520-202-1889
Practice Address - Street 1:2482 N PALO VERDE AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2548
Practice Address - Country:US
Practice Address - Phone:520-327-4505
Practice Address - Fax:520-202-1889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5053OtherLICENSE