1992224455 NPI number — CODAC HEALTH RECOVERY AND WELLNESS

Table of content: (NPI 1992224455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992224455 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:
CODAC MEDICATION ASSISTED ADDICTION TREATMENT
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:
1992224455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2017
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:
380 E FORT LOWELL 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:
85705-3985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-202-1796
Provider Business Practice Location Address Fax Number:
520-792-4977
Provider Enumeration Date:
09/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
NAVARRO-HERNANDEZ
Authorized Official First Name:
NORA
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
520-327-4505

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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