=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164852471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANACEA SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2013
-----------------------------------------------------
Last Update Date | 11/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 DOS RIOS ST STE A1
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95811-0442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-930-0066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3152 N MILLBROOK AVE SUITE D
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93703-1400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-241-0364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. PHILLIP COWINGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 559-241-0364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------