Provider Demographics
NPI:1992224455
Name:CODAC HEALTH RECOVERY AND WELLNESS
Entity Type:Organization
Organization Name:CODAC HEALTH RECOVERY AND WELLNESS
Other - Org Name:CODAC MEDICATION ASSISTED ADDICTION TREATMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NORA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAVARRO-HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-4505
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 1:380 E FORT LOWELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-3985
Practice Address - Country:US
Practice Address - Phone:520-202-1796
Practice Address - Fax:520-792-4977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ000000Medicaid