Provider Demographics
NPI:1790842755
Name:NATIONAL MENTOR HEALTH CARE, LLC
Entity Type:Organization
Organization Name:NATIONAL MENTOR HEALTH CARE, LLC
Other - Org Name:ARIZONA 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 1:3838 N CENTRAL AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1997
Mailing Address - Country:US
Mailing Address - Phone:480-646-6175
Mailing Address - Fax:617-790-4271
Practice Address - Street 1:3838 N CENTRAL AVE STE 1200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1997
Practice Address - Country:US
Practice Address - Phone:480-646-6175
Practice Address - Fax:617-790-4271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2023-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2477320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS884206Medicaid