Basic Information
| Provider Information | |||||||||
| NPI: | 1043462864 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PANACEA SERVICES, INC. AT LAGUNA CREEK HIGH SCHOOL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3353 BRADSHAW RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168544564 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9050 VICINO DR | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957585859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168544564 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2008 | ||||||||
| LastUpdateDate: | 12/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | SEASTROM | ||||||||
| AuthorizedOfficialFirstName: | TRISHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9168544564 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PANACEA SERVICES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | BA, CADC II, CAMF | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.