Healthcare Provider Details

I. General information

NPI: 1639733058
Provider Name (Legal Business Name): MENTOR ABI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 CORPORATE CENTRE DR STE 120
LAWRENCE KS
66047-1002
US

IV. Provider business mailing address

4910 CORPORATE CENTRE DR STE 120
LAWRENCE KS
66047-1002
US

V. Phone/Fax

Practice location:
  • Phone: 618-559-5304
  • Fax:
Mailing address:
  • Phone: 618-559-5304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SERGIO P CRUZ
Title or Position: CFO
Credential:
Phone: 781-708-9444