NPIMap

Organization Active NPI

Codac Inc

Doing business as Codac Cranston

  • Methadone Clinic
  • Cranston, RI
National Provider Identifier
1295731321
Registry record updated Dec 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Methadone ClinicTaxonomy code 261QM2800X
License
605.01 Issued in RI
Legal business name
CODAC INC
Doing business as
Codac Cranston
Practice address
1052 Park Ave
Codac Cranston
Cranston, RI 02910
Phone
(401) 461-5056
Fax
(401) 943-2167
NPI assigned
Jun 23, 2005
Last updated
Dec 21, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 21, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Alisha M Bourdeau, BS
Title
Cfo
Phone
(401) 275-5038

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction Medicine (Family Medicine) Physician 207QA0401X ACF01632-01 RI
Public Health or Welfare Agency 251K00000X 605.1 RI
Methadone Clinic 261QM2800X 605.01 RI Primary
Primary Care Clinic/Center 261QP2300X ACF01632-01 RI
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X 605.1 RI
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X 605.01 RI
Substance Use Disorder Rehabilitation Hospital Unit 276400000X 605.1 RI
Peer Specialist 175T00000X NU

Addresses

Primary practice location

1052 Park Ave
Codac Cranston
Cranston, RI 02910

Mailing address

1052 Park Ave
Cranston, RI 02910
Phone (401) 275-5038

Other names 1

  • Codac Cranston Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in RI
Opioid treatment program
Medicare-enrolled since Mar 1, 2020

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200618002698 RI Part B Supplier - Opioid Treatment Program (Otp) 4183046212 7 other NPIs on this enrollment
Practice locations: Warwick, RI; Saunderstown, RI; Providence, RI; Newport, RI; Cranston, RI; East Providence, RI

Other NPIs on the same Medicare enrollment 7

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Codac Inc10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1119484800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1640044800000",
    "number": "1295731321",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1052 PARK AVE",
            "city": "CRANSTON",
            "state": "RI",
            "postal_code": "02910",
            "telephone_number": "401-275-5038",
            "fax_number": "401-942-3590"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1052 PARK AVE",
            "address_2": "CODAC CRANSTON",
            "city": "CRANSTON",
            "state": "RI",
            "postal_code": "02910",
            "telephone_number": "401-461-5056",
            "fax_number": "401-943-2167"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CODAC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-06-23",
        "last_updated": "2021-12-21",
        "certification_date": "2021-12-21",
        "status": "A",
        "authorized_official_last_name": "BOURDEAU",
        "authorized_official_first_name": "ALISHA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "401-275-5038",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "BS"
    },
    "taxonomies": [
        {
            "code": "207QA0401X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Addiction Medicine",
            "state": "RI",
            "license": "ACF01632-01",
            "primary": false
        },
        {
            "code": "251K00000X",
            "taxonomy_group": "",
            "desc": "Public Health or Welfare",
            "state": "RI",
            "license": "605.1",
            "primary": false
        },
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": "RI",
            "license": "605.01",
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "RI",
            "license": "ACF01632-01",
            "primary": false
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": "RI",
            "license": "605.1",
            "primary": false
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": "RI",
            "license": "605.01",
            "primary": false
        },
        {
            "code": "276400000X",
            "taxonomy_group": "",
            "desc": "Rehabilitation, Substance Use Disorder Unit",
            "state": "RI",
            "license": "605.1",
            "primary": false
        },
        {
            "code": "175T00000X",
            "taxonomy_group": "",
            "desc": "Peer Specialist",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Codac Cranston",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Codac Cranston",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cranston, RI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 21, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.