=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801680004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MDRI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2025
-----------------------------------------------------
Last Update Date | 04/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1239 HARTFORD AVE STE 3
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02919-7137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-398-0288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1407 S COUNTY TRL STE 431
-----------------------------------------------------
City | EAST GREENWICH
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02818-1679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-398-0288
-----------------------------------------------------
Fax | 401-398-0288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DESIREE COFFEY COFFEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-398-0288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------