1205248879 NPI number — NATIONAL MENTOR HEATLTHCARE, LLC

Table of content: (NPI 1205248879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205248879 NPI number — NATIONAL MENTOR HEATLTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATIONAL MENTOR HEATLTHCARE, LLC
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:
1205248879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
313 CONGRESS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02210-1218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-388-5150
Provider Business Mailing Address Fax Number:
617-790-4271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2133 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNN HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32444-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-785-0605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
BRETT
Authorized Official Middle Name:
IAN
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
800-388-5150

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 012037000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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