1700300092 NPI number — MARTINEZ GROUP HOME, LLC

Table of content: (NPI 1700300092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700300092 NPI number — MARTINEZ GROUP HOME, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTINEZ GROUP HOME, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700300092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14918 SW 15 LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-450-7645
Provider Business Mailing Address Fax Number:
786-360-5343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14918 SW 15 LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-450-7645
Provider Business Practice Location Address Fax Number:
786-360-5343
Provider Enumeration Date:
07/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
NELSON
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-450-7645

Provider Taxonomy Codes

  • Taxonomy code: 320700000X , with the licence number:  L11-1108-GH , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010236500 . This is a "MEDICAID WAIVER PROVIDE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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