Provider Demographics
NPI:1922322502
Name:MENTOR ABI
Entity Type:Organization
Organization Name:MENTOR ABI
Other - Org Name:NEURORESTORATIVE PENNSYLVANIA
Other - Org Type:Doing Business As
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:
Mailing Address - Fax:
Practice Address - Street 1:6816 W LAKE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:PA
Practice Address - Zip Code:16415-1645
Practice Address - Country:US
Practice Address - Phone:813-626-1444
Practice Address - Fax:813-621-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2022-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children