Provider Demographics
NPI:1629385661
Name:OBANGUALA, INC
Entity Type:Organization
Organization Name:OBANGUALA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIANA
Authorized Official - Middle Name:P
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-863-7307
Mailing Address - Street 1:719 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-4553
Mailing Address - Country:US
Mailing Address - Phone:305-863-7307
Mailing Address - Fax:305-863-7347
Practice Address - Street 1:719 E 9TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4553
Practice Address - Country:US
Practice Address - Phone:305-863-7307
Practice Address - Fax:305-863-7347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251C00000X, 251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001248200Medicaid
FL003014900Medicaid