Healthcare Provider Details

I. General information

NPI: 1922322502
Provider Name (Legal Business Name): MENTOR ABI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 09/25/2022
Certification Date: 09/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6816 W LAKE RD
FAIRVIEW PA
16415-1645
US

IV. Provider business mailing address

980 WASHINGTON ST STE 306
DEDHAM MA
02026-6797
US

V. Phone/Fax

Practice location:
  • Phone: 813-626-1444
  • Fax: 813-621-0770
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

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