=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679382949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MNR INDUSTRIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2025
-----------------------------------------------------
Last Update Date | 04/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2570 QUARRY LAKE DR
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209-3759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-842-6238
-----------------------------------------------------
Fax | 443-842-6239
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1505 E CHURCHVILLE RD
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21014-4742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-420-6970
-----------------------------------------------------
Fax | 410-420-6650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER OF CREDENTIALING
-----------------------------------------------------
Name | TAVIANNA BOST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-420-6970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------