Provider Demographics
NPI:1649911157
Name:CODAC HEALTH RECOVERY AND WELLNESS
Entity type:Organization
Organization Name:CODAC HEALTH RECOVERY AND WELLNESS
Other - Org Name:
Other - Org Type:
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:
Mailing Address - Fax:
Practice Address - Street 1:4585 E SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-5309
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:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care