Provider Demographics
NPI:1841416898
Name:CODAC BEHAVIORAL HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:CODAC BEHAVIORAL HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:W.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-4505
Mailing Address - Street 1:127 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-2005
Mailing Address - Country:US
Mailing Address - Phone:520-327-4505
Mailing Address - Fax:520-202-1889
Practice Address - Street 1:3550 N 1ST AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-1770
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:2007-04-18
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2543261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ71967Medicare ID - Type UnspecifiedMEDICARE ID NUMBER