Provider Demographics
NPI:1972856011
Name:THE MENTOR NETWORK
Entity Type:Organization
Organization Name:THE MENTOR NETWORK
Other - Org Name:FLORIDA MENTOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-388-5150
Mailing Address - Street 1:313 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-1218
Mailing Address - Country:US
Mailing Address - Phone:800-388-5150
Mailing Address - Fax:617-790-4271
Practice Address - Street 1:1725 FIFTH ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5107
Practice Address - Country:US
Practice Address - Phone:386-274-4172
Practice Address - Fax:386-274-7629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4021095315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities