1629163563 NPI number — MARTIN DE PORRES GROUP HOMES

Table of content: (NPI 1629163563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629163563 NPI number — MARTIN DE PORRES GROUP HOMES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN DE PORRES GROUP HOMES
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:
1629163563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
136 25 218TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD GARDENS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11413-2226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-527-0606
Provider Business Mailing Address Fax Number:
718-723-1528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
136 25 218TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD GARDENS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11413-2226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-527-0606
Provider Business Practice Location Address Fax Number:
718-723-1528
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROFRANO
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
718-527-0606

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  00328116 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00328116 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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