Healthcare Provider Details

I. General information

NPI: 1629385661
Provider Name (Legal Business Name): OBANGUALA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 E 9TH ST
HIALEAH FL
33010-4553
US

IV. Provider business mailing address

719 E 9TH ST
HIALEAH FL
33010-4553
US

V. Phone/Fax

Practice location:
  • Phone: 305-863-7307
  • Fax: 305-863-7347
Mailing address:
  • Phone: 305-863-7307
  • Fax: 305-863-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateFL

VIII. Authorized Official

Name: MARIANA P ABRAHAM
Title or Position: PRESIDENT
Credential:
Phone: 305-863-7307