Provider Demographics
NPI:1144352360
Name:NATIONAL MENTOR HEALTHCARE, LLC
Entity type:Organization
Organization Name:NATIONAL MENTOR HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:STATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-790-8580
Mailing Address - Street 1:3125 POPLARWOOD CT
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1084
Mailing Address - Country:US
Mailing Address - Phone:919-790-8580
Mailing Address - Fax:919-866-3255
Practice Address - Street 1:542 WILLIAMSON RD
Practice Address - Street 2:SUITE 6
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8193
Practice Address - Country:US
Practice Address - Phone:919-790-8580
Practice Address - Fax:919-866-3255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8303026Medicaid
=========OtherFEDERAL TAX ID #