Healthcare Provider Details

I. General information

NPI: 1174691554
Provider Name (Legal Business Name): PANACEA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3152 N MILLBROOK AVE STE D
FRESNO CA
93703-1459
US

IV. Provider business mailing address

3152 N MILLBROOK AVE STE D
FRESNO CA
93703-1459
US

V. Phone/Fax

Practice location:
  • Phone: 559-241-0364
  • Fax:
Mailing address:
  • Phone: 559-241-0364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILLIP COWINGS
Title or Position: DIRECTOR
Credential:
Phone: 559-241-0364