Provider Demographics
NPI:1619018033
Name:NORTHERN RHODE ISLAND COLLABORATIVE
Entity Type:Organization
Organization Name:NORTHERN RHODE ISLAND COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MACDONNELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:401-658-5790
Mailing Address - Street 1:2352 MENDON RD
Mailing Address - Street 2:UNIT 6
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-3715
Mailing Address - Country:US
Mailing Address - Phone:401-658-5790
Mailing Address - Fax:401-658-4012
Practice Address - Street 1:2352 MENDON RD
Practice Address - Street 2:UNIT 6
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-3715
Practice Address - Country:US
Practice Address - Phone:401-658-5790
Practice Address - Fax:401-658-4012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251P0200X
RI251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251300000XAgenciesLocal Education Agency (LEA)
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI08120Medicaid