Provider Demographics
NPI:1629190269
Name:MENTOR ABI, LLC
Entity Type:Organization
Organization Name:MENTOR ABI, LLC
Other - Org Name:BRAINTREE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:P
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-708-9444
Mailing Address - Street 1:980 WASHINGTON ST STE 306
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-6797
Mailing Address - Country:US
Mailing Address - Phone:781-708-9444
Mailing Address - Fax:
Practice Address - Street 1:1107 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1819
Practice Address - Country:US
Practice Address - Phone:781-708-9444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1901702Medicaid