Basic Information
| Provider Information | |||||||||
| NPI: | 1588848824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PANACEA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2745 N HUGHES AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937053726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592410364 | ||||||||
| FaxNumber: | 5592410342 | ||||||||
| Practice Location | |||||||||
| Address1: | 2745 N HUGHES AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937053726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592410364 | ||||||||
| FaxNumber: | 5592410342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2007 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | GOLDEN | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5592410364 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PANACEA, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.