Healthcare Provider Details

I. General information

NPI: 1538050687
Provider Name (Legal Business Name): FUNDACCION MI ANGEL MANUEL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 07/15/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROAD 110 KM 0.3
AGUADILLA PR
00603
US

IV. Provider business mailing address

HC 1 BOX 7066
MOCA PR
00676-9570
US

V. Phone/Fax

Practice location:
  • Phone: 787-364-4605
  • Fax:
Mailing address:
  • Phone: 787-364-4605
  • Fax: 787-364-4605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MISS MARLINE HERNANDEZ
Title or Position: PRESIDENTA
Credential:
Phone: 787-364-4605