1679793301 NPI number — CODAC BEHAVIORAL HEALTH SERVICES OF PIMA COUNTY, INC

Table of content: (NPI 1679793301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679793301 NPI number — CODAC BEHAVIORAL HEALTH SERVICES OF PIMA COUNTY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CODAC BEHAVIORAL HEALTH SERVICES OF PIMA COUNTY, 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:
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:
1679793301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 S 5TH AVE
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:
85701-2005
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:
3550 N 1ST AVE
Provider Second Line Business Practice Location Address:
SUITE 100, 125, 150
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85719-1770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-327-4505
Provider Business Practice Location Address Fax Number:
520-202-1889
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
W.
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
520-327-4505

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  BH-2543 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 237325 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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