Provider Demographics
NPI:1851604599
Name:NATIONAL MENTOR HEALTHCARE
Entity Type:Organization
Organization Name:NATIONAL MENTOR HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-765-8912
Mailing Address - Street 1:7 OAK BRANCH DR STE C
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-2392
Mailing Address - Country:US
Mailing Address - Phone:336-856-1140
Mailing Address - Fax:
Practice Address - Street 1:7 OAK BRANCH DR STE C
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-2392
Practice Address - Country:US
Practice Address - Phone:336-856-1140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1041C0700X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300268HMedicaid