1578070447 NPI number — CODAC HEALTH RECOVERY AND WELLNESS

Table of content: (NPI 1578070447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578070447 NPI number — CODAC HEALTH RECOVERY AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CODAC HEALTH RECOVERY AND WELLNESS
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:
Provider Other Organization Name Type Code:
6
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:
1578070447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2018
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 STE 202
Provider Second Line Business Mailing Address:
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:
630 N ALVERNON WAY STE 161
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:
85711-1895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-318-9222
Provider Business Practice Location Address Fax Number:
520-318-9094
Provider Enumeration Date:
01/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
AXINN
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTRACTS AND CREDENTIALING MANAGER
Authorized Official Telephone Number:
520-202-1755

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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