Healthcare Provider Details

I. General information

NPI: 1386170504
Provider Name (Legal Business Name): MENTOR ABI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 CAVALIER WAY
SIOUX CITY IA
51109-1176
US

IV. Provider business mailing address

2021 CAVALIER WAY
SIOUX CITY IA
51109-1176
US

V. Phone/Fax

Practice location:
  • Phone: 563-321-5706
  • Fax: 319-538-0397
Mailing address:
  • Phone: 563-321-5706
  • Fax: 319-538-0397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY SMITH
Title or Position: STATE DIRECTOR
Credential:
Phone: 563-321-5706