MEDICARE: NATIONAL MENTOR HEALTHCARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200943350P	OTHER	IN	PROVIDER NUMBER

General Provider Information

NPI Number	:	1326347451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONAL MENTOR HEALTHCARE, LLC

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

Provider Business Practice Location Address
First Line	:	7625 W 275 N
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-9306
Country	:	US
Telephone Number	:	317-581-2380
Fax Number	:

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

Provider Enumeration Date	:	03/15/2011
Last Update Date	:	03/05/2023

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