Healthcare Provider Details

I. General information

NPI: 1669592234
Provider Name (Legal Business Name): MENTOR ABI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 SENECA DR
BLACKSBURG VA
24060-2464
US

IV. Provider business mailing address

280 MERRIMACK ST
LAWRENCE MA
01843-1779
US

V. Phone/Fax

Practice location:
  • Phone: 540-951-1902
  • Fax: 540-951-9228
Mailing address:
  • Phone: 800-743-6802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number916
License Number StateVA

VIII. Authorized Official

Name: MARY PATRICIA RODENBERG-ROBERTS
Title or Position: VICE PRES & SR ASST GENERAL COUNSEL
Credential:
Phone: 952-836-2234