MEDICARE: PANACEA SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency		CA

General Provider Information

NPI Number	:	1295087963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANACEA SERVICES, INC.

Provider Business Mailing Address
First Line	:	3353 BRADSHAW RD
Second Line	:	SUITE 106
City	:	SACRAMENTO
State	:	CA
Zip	:	95827-2607
Country	:	US
Telephone Number	:	916-854-4564
Fax Number	:

Provider Business Practice Location Address
First Line	:	8365 WHITELOCK PKWY
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95757-5930
Country	:	US
Telephone Number	:	916-683-7670
Fax Number	:

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

Provider Enumeration Date	:	10/05/2012
Last Update Date	:	10/05/2012

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