Healthcare Provider Details

I. General information

NPI: 1326298803
Provider Name (Legal Business Name): PANACEA ALLIANCE CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 TREE BLVD STE 5
ST AUGUSTINE FL
32084-5715
US

IV. Provider business mailing address

1750 TREE BLVD STE 5
ST AUGUSTINE FL
32084-5719
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-0672
  • Fax: 904-342-0673
Mailing address:
  • Phone: 904-342-0672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME83444
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME 83444
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ENEIDA GOMEZ
Title or Position: OWNER
Credential: MD
Phone: 904-342-0672