Provider Demographics
NPI:1821435801
Name:NATIONAL MENTOR HOLDINGS INC
Entity Type:Organization
Organization Name:NATIONAL MENTOR HOLDINGS INC
Other - Org Name:ILLINOIS MENTOR COMMUNITY SERVICES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUTANEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-276-1194
Mailing Address - Street 1:2005 W BELTLINE HWY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2314
Mailing Address - Country:US
Mailing Address - Phone:608-276-1191
Mailing Address - Fax:608-276-1184
Practice Address - Street 1:600 HOLIDAY PLAZA DR
Practice Address - Street 2:SUITE 400
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2241
Practice Address - Country:US
Practice Address - Phone:708-679-9137
Practice Address - Fax:708-503-6267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL461224998Medicaid
IL=========Medicaid