NPIMap

Organization Active NPI

Codac Inc

  • Methadone Clinic
  • Pawtucket, RI
National Provider Identifier
1629632609
Registry record updated Dec 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Methadone ClinicTaxonomy code 261QM2800X
Legal business name
CODAC INC
Practice address
600 Pawtucket Ave
Pawtucket, RI 02860-6059
Phone
(401) 808-6278
Fax
(401) 808-6957
NPI assigned
Apr 25, 2019
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
Alisha M Bourdeau
Title
Cfo
Phone
(401) 275-5038

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Peer SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 175T00000X
Public Health or Welfare Agency 251K00000X
Methadone Clinic 261QM2800X Primary
Primary Care Clinic/Center 261QP2300X
Rehabilitation Clinic/Center 261QR0400X
Substance Use Disorder Rehabilitation Clinic/Center 261QR0405X

Addresses

Primary practice location

600 Pawtucket Ave
Pawtucket, RI 02860-6059

Mailing address

1052 Park Ave
Cranston, RI 02910-3225
Phone (401) 275-5038

Other identifiers 1

IdentifierTypeStateIssuer
CO71983MedicaidRI

Other names 1

  • CODAC Pawtucket Ave Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address abourdeau@codacinc.org Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in RI

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

Locations

600 Pawtucket Ave
Pawtucket, RI 02860
Phone (401) 728-2200

NPI Registry JSON

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

{
    "created_epoch": "1556150400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1640044800000",
    "number": "1629632609",
    "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": "401-275-5038",
            "fax_number": "401-942-3590"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 PAWTUCKET AVE",
            "city": "PAWTUCKET",
            "state": "RI",
            "postal_code": "028606059",
            "telephone_number": "401-808-6278",
            "fax_number": "401-808-6957"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CODAC INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-04-25",
        "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"
    },
    "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": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM2800X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Methadone",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0405X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation, Substance Use Disorder",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "CO71983",
            "state": "RI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "abourdeau@codacinc.org",
            "affiliation": "N",
            "endpointDescription": "emial",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "1052 Park Ave",
            "city": "Cranston",
            "state": "RI",
            "country_code": "US",
            "postal_code": "029103225",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "CODAC Pawtucket Ave",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pawtucket, 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.