Provider Demographics
NPI:1346304698
Name:NATIONAL MENTOR HEALTHCARE, LLC
Entity Type:Organization
Organization Name:NATIONAL MENTOR HEALTHCARE, LLC
Other - Org Name:FLORIDA MENTOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-388-5150
Mailing Address - Street 1:313 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210-1218
Mailing Address - Country:US
Mailing Address - Phone:800-388-5150
Mailing Address - Fax:617-790-4271
Practice Address - Street 1:222 GREENRIDGE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-3136
Practice Address - Country:US
Practice Address - Phone:850-484-3276
Practice Address - Fax:850-479-0951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2023-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4111096315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4111096OtherOPERATING LICENSE AHCA