Provider Demographics
NPI:1447944111
Name:CODAC HEALTHCARE, LLC
Entity type:Organization
Organization Name:CODAC HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-275-5038
Mailing Address - Street 1:1052 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-3225
Mailing Address - Country:US
Mailing Address - Phone:401-275-5038
Mailing Address - Fax:401-942-3590
Practice Address - Street 1:349 HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-3005
Practice Address - Country:US
Practice Address - Phone:401-942-1450
Practice Address - Fax:401-946-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty