Healthcare Provider Details

I. General information

NPI: 1821349697
Provider Name (Legal Business Name): PANACEA SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5715 SKVARLA AVE
MCCLELLAN CA
95652-2424
US

IV. Provider business mailing address

3353 BRADSHAW RD SUITE 106
SACRAMENTO CA
95827-2607
US

V. Phone/Fax

Practice location:
  • Phone: 916-286-5161
  • Fax:
Mailing address:
  • Phone: 916-854-4564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. TRISHA SEASTROM
Title or Position: EXECUTIVE DIRECTOR
Credential: BA, LAADC, CADC II
Phone: 916-854-4564