Provider Demographics
NPI:1861384422
Name:MENTOVIA WELLNESS CENTER LLC
Entity type:Organization
Organization Name:MENTOVIA WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-441-8318
Mailing Address - Street 1:23609 104TH AVE SE STE 101
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-3326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23609 104TH AVE SE STE 101
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-3326
Practice Address - Country:US
Practice Address - Phone:773-441-8318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)