Provider Demographics
NPI:1629163563
Name:MARTIN DE PORRES GROUP HOMES
Entity Type:Organization
Organization Name:MARTIN DE PORRES GROUP HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:ROFRANO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-527-0606
Mailing Address - Street 1:136 25 218TH STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2226
Mailing Address - Country:US
Mailing Address - Phone:718-527-0606
Mailing Address - Fax:718-723-1528
Practice Address - Street 1:136 25 218TH STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-2226
Practice Address - Country:US
Practice Address - Phone:718-527-0606
Practice Address - Fax:718-723-1528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00328116322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00328116Medicaid