NPIMap

Organization Active NPI

Codac Inc

Doing business as Codac East Bay

  • Methadone Clinic
  • East Providence, RI
National Provider Identifier
1376769919
Registry record updated Dec 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Methadone ClinicTaxonomy code 261QM2800X
License
605.02 Issued in RI
Legal business name
CODAC INC
Doing business as
Codac East Bay
Practice address
850 Waterman Ave
Codac East Bay
East Providence, RI 02914
Phone
(401) 434-4999
Fax
(401) 434-6116
NPI assigned
Apr 18, 2007
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 9

Specialty (taxonomy)CodeLicenseStatePrimary
Peer SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 175T00000X
Addiction Medicine (Family Medicine) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207QA0401X ACF01632-03 RI
Public Health or Welfare Agency 251K00000X 605.2 RI
Methadone Clinic 261QM2800X 605.2 RI
Methadone Clinic 261QM2800X 605.02 RI Primary
Primary Care Clinic/Center 261QP2300X ACF01632-03 RI
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X 605.2 RI
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X 605.02 RI
Substance Use Disorder Rehabilitation Hospital Unit 276400000X 605.2 RI

Addresses

Primary practice location

850 Waterman Ave
Codac East Bay
East Providence, RI 02914

Mailing address

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

Other names 1

  • Codac East Bay 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
This NPI is an additional NPI on the 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.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1176854400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1640044800000",
    "number": "1376769919",
    "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": "850 WATERMAN AVE",
            "address_2": "CODAC EAST BAY",
            "city": "EAST PROVIDENCE",
            "state": "RI",
            "postal_code": "02914",
            "telephone_number": "401-434-4999",
            "fax_number": "401-434-6116"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CODAC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-18",
        "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": "175T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Peer Specialist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207QA0401X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine, Addiction Medicine",
            "state": "RI",
            "license": "ACF01632-03",
            "primary": false
        },
        {
            "code": "251K00000X",
            "taxonomy_group": "",
            "desc": "Public Health or Welfare",
            "state": "RI",
            "license": "605.2",
            "primary": false
        },
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": "RI",
            "license": "605.2",
            "primary": false
        },
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": "RI",
            "license": "605.02",
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "RI",
            "license": "ACF01632-03",
            "primary": false
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": "RI",
            "license": "605.2",
            "primary": false
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": "RI",
            "license": "605.02",
            "primary": false
        },
        {
            "code": "276400000X",
            "taxonomy_group": "",
            "desc": "Rehabilitation, Substance Use Disorder Unit",
            "state": "RI",
            "license": "605.2",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Codac East Bay",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Codac East Bay",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in East Providence, 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.