Provider Demographics
NPI:1639476617
Name:MENTOR ABI
Entity Type:Organization
Organization Name:MENTOR ABI
Other - Org Name:NEURORESTORATIVE RHODE ISLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. BUSINESS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-529-3060
Mailing Address - Street 1:639 GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-5366
Mailing Address - Country:US
Mailing Address - Phone:781-356-6330
Mailing Address - Fax:
Practice Address - Street 1:4219 S COUNTY TRL
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02813-3628
Practice Address - Country:US
Practice Address - Phone:401-364-8717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services