NPIMap

Organization Active NPI

Codac Inc

Doing business as CODAC North Main

  • Methadone Clinic
  • Providence, RI
National Provider Identifier
1558712034
Registry record updated Apr 25, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Methadone ClinicTaxonomy code 261QM2800X
License
605.07 Issued in RI
Legal business name
CODAC INC
Doing business as
CODAC North Main
Practice address
528 N Main St
Providence, RI 02904-5757
Phone
(401) 808-4278
Fax
(401) 808-6957
NPI assigned
Jun 27, 2016
Last updated
Apr 25, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 25, 2019

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

Authorized official

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

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Peer SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 175T00000X
Public Health or Welfare Agency 251K00000X 605.07 RI
Health Service Clinic/Center 261QH0100X 605.07 RI
Methadone Clinic 261QM2800X 605.07 RI Primary
Primary Care Clinic/Center 261QP2300X ACF01632 RI
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X 605.07 RI
Substance Use Disorder Rehabilitation Hospital Unit 276400000X 605.07 RI

Addresses

Primary practice location

528 N Main St
Providence, RI 02904-5757

Mailing address

1052 Park Ave
Cranston, RI 02910-3225
Phone (401) 275-5039

Other identifiers 1

IdentifierTypeStateIssuer
CI01382MedicaidRI

Other names 1

  • CODAC North Main Doing business as

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": "1466985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1556150400000",
    "number": "1558712034",
    "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": "029103225",
            "telephone_number": "401-275-5039",
            "fax_number": "401-942-3590"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "528 N MAIN ST",
            "city": "PROVIDENCE",
            "state": "RI",
            "postal_code": "029045757",
            "telephone_number": "401-808-4278",
            "fax_number": "401-808-6957"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CODAC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-06-27",
        "last_updated": "2019-04-25",
        "status": "A",
        "authorized_official_last_name": "BOURDEAU",
        "authorized_official_first_name": "ALISHA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "401-275-5038",
        "authorized_official_credential": "BS"
    },
    "taxonomies": [
        {
            "code": "175T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Peer Specialist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251K00000X",
            "taxonomy_group": "",
            "desc": "Public Health or Welfare",
            "state": "RI",
            "license": "605.07",
            "primary": false
        },
        {
            "code": "261QH0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Health Service",
            "state": "RI",
            "license": "605.07",
            "primary": false
        },
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": "RI",
            "license": "605.07",
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "RI",
            "license": "ACF01632",
            "primary": false
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": "RI",
            "license": "605.07",
            "primary": false
        },
        {
            "code": "276400000X",
            "taxonomy_group": "",
            "desc": "Rehabilitation, Substance Use Disorder Unit",
            "state": "RI",
            "license": "605.07",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "CI01382",
            "state": "RI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CODAC North Main",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CODAC North Main",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Providence, RI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 25, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.