1649574252 NPI number — MENTOR ABI

Table of content: (NPI 1649574252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649574252 NPI number — MENTOR ABI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENTOR ABI
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEURORESTORATIVE WISCONSIN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649574252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10150 HIGHLAND MANOR DR STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33610-9712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-626-1444
Provider Business Mailing Address Fax Number:
813-902-6719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5310 BUENA PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53185-2907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-534-4864
Provider Business Practice Location Address Fax Number:
262-546-0801
Provider Enumeration Date:
12/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CUTLER
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
618-457-4729

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  0013091 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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