Organization
MENTOR IDAHO, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ROBIN JACOME (SR. BUSINESS DIRECTOR)
(951) 201-5914
Entity
Organization
Contact information
Practice address
1001 W BROADWAY AVE APT A104, MERIDIAN, ID 83642-3730
(951) 201-5914
Mailing address
9166 ANAHEIM PL STE 200, RANCHO CUCAMONGA, CA 91730-8547
(951) 201-5914
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
Primary
—
—
Other
Enumeration date
05/26/2021
Last updated
05/26/2021
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