1467475434 NPI number — CODAC HEALTH, RECOVERY & WELLNESS, INC.

Table of content: (NPI 1467475434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467475434 NPI number — CODAC HEALTH, RECOVERY & WELLNESS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CODAC HEALTH, RECOVERY & WELLNESS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAS AMIGAS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467475434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 E FORT LOWELL RD
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85719-2378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-327-4505
Provider Business Mailing Address Fax Number:
520-202-1889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 N SILVERBELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85745-2626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-202-1716
Provider Business Practice Location Address Fax Number:
520-202-1702
Provider Enumeration Date:
07/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REGNIER
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
520-327-4505

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  BH-939 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BH-939 . This is a "ADHS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 408874 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".