1306110770 NPI number — MENTOR ABI,LLC D/B/A NEURORESTORATIVE IOWA

Table of content: (NPI 1306110770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306110770 NPI number — MENTOR ABI,LLC D/B/A NEURORESTORATIVE IOWA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENTOR ABI,LLC D/B/A NEURORESTORATIVE IOWA
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:
Provider Other Organization Name Type Code:
6
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:
1306110770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2825
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62902-2825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-529-3060
Provider Business Mailing Address Fax Number:
618-529-8119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4569 JENN LN NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52240-7969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-203-6797
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMSON
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL VP FOR THE CENTRAL DIV
Authorized Official Telephone Number:
618-529-3060

Provider Taxonomy Codes

  • Taxonomy code: 283X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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