=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164913919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANACEA RECOVERY ADVOCATES & WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2018
-----------------------------------------------------
Last Update Date | 05/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 PORTAGE TRAIL EXT STE 3
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44313-8250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 234-312-9127
-----------------------------------------------------
Fax | 234-312-9579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 PORTAGE TRAIL EXT STE 3
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44313-8250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 234-312-9127
-----------------------------------------------------
Fax | 234-312-9579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | FAITH PALMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 234-312-9127
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------