=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225281975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONAL MENTOR HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2008
-----------------------------------------------------
Last Update Date | 03/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 MCGEHEE RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36111-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-280-3330
-----------------------------------------------------
Fax | 334-280-1007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 MCGEHEE RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36111-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-280-3330
-----------------------------------------------------
Fax | 334-280-1007
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | BRETT IAN COHEN
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 800-388-5150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 040905
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------