Provider Demographics
NPI:1396806881
Name:SAINT JOHNS HOME FOR BOYS
Entity type:Organization
Organization Name:SAINT JOHNS HOME FOR BOYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPECIAL SERVICES & OPER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARVING
Authorized Official - Middle Name:C
Authorized Official - Last Name:IRIZARRY
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:718-945-2800
Mailing Address - Street 1:150 BEACH 110TH STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694
Mailing Address - Country:US
Mailing Address - Phone:718-945-2800
Mailing Address - Fax:718-945-4662
Practice Address - Street 1:150 BEACH 110TH STREET
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694
Practice Address - Country:US
Practice Address - Phone:718-945-2800
Practice Address - Fax:718-945-4662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X
NY2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00327748Medicaid