Provider Demographics
NPI:1700300092
Name:MARTINEZ GROUP HOME, LLC
Entity Type:Organization
Organization Name:MARTINEZ GROUP HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-450-7645
Mailing Address - Street 1:14918 SW 15 LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33194
Mailing Address - Country:US
Mailing Address - Phone:305-450-7645
Mailing Address - Fax:786-360-5343
Practice Address - Street 1:14918 SW 15 LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33194
Practice Address - Country:US
Practice Address - Phone:305-450-7645
Practice Address - Fax:786-360-5343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL11-1108-GH320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010236500OtherMEDICAID WAIVER PROVIDE