Healthcare Provider Details

I. General information

NPI: 1710099080
Provider Name (Legal Business Name): MENTOR ABI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46406 W LEE HUGHES RD
HAMMOND LA
70401-4757
US

IV. Provider business mailing address

980 WASHINGTON ST STE 306
DEDHAM MA
02026-6797
US

V. Phone/Fax

Practice location:
  • Phone: 501-707-3262
  • Fax: 501-753-8204
Mailing address:
  • Phone: 781-708-9444
  • Fax: 501-753-8204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number004
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number004
License Number StateLA

VIII. Authorized Official

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