Healthcare Provider Details

I. General information

NPI: 1144382136
Provider Name (Legal Business Name): NATIONAL MENTOR HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 03/04/2023
Certification Date: 03/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NE CAPRONA AVE
PORT ST LUCIE FL
34983-8450
US

IV. Provider business mailing address

313 CONGRESS ST
BOSTON MA
02210-1218
US

V. Phone/Fax

Practice location:
  • Phone: 772-879-1925
  • Fax:
Mailing address:
  • Phone: 800-388-5150
  • Fax: 617-790-4271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number4017096
License Number StateFL

VIII. Authorized Official

Name: BRETT IAN COHEN
Title or Position: COO
Credential:
Phone: 800-388-5150