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General NPI Number Information
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NPI Number | 1679148175
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Entity Type | Organization
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Legal Business Name | MENTOR IDAHO, LLC
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Dates
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Enumeration Date | 05/26/2021
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Last Update Date | 05/26/2021
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Provider Practice Location Address
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Address Line | 1001 W BROADWAY AVE APT A104
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City | MERIDIAN
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State | ID
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Zip | 83642-3730
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Country | US
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Telephone | 951-201-5914
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Fax |
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Provider Business Mailing Address
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Address Line | 9166 ANAHEIM PL STE 200
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-8547
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Country | US
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Telephone | 951-201-5914
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Fax |
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Authorized Official
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Title or Position | SR. BUSINESS DIRECTOR
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Name | ROBIN JACOME
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Credential |
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Telephone | 951-201-5914
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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License Number State |
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