Provider Demographics
NPI:1417267527
Name:NATIONAL MENTOR HEALTHCARE, LLC
Entity Type:Organization
Organization Name:NATIONAL MENTOR HEALTHCARE, LLC
Other - Org Name:INDIANA MENTOR ADULT FOSTER CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHNKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-581-2380
Mailing Address - Street 1:8925 N MERIDIAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2386
Mailing Address - Country:US
Mailing Address - Phone:317-581-2380
Mailing Address - Fax:317-581-2378
Practice Address - Street 1:1057 E JOHNSON RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-5493
Practice Address - Country:US
Practice Address - Phone:317-581-2380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200943350GOtherPROVIDER NUMBER