Provider Demographics
NPI:1174691554
Name:PANACEA, INC.
Entity type:Organization
Organization Name:PANACEA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:COWINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-241-0364
Mailing Address - Street 1:3152 N MILLBROOK AVE STE D
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-1459
Mailing Address - Country:US
Mailing Address - Phone:559-241-0364
Mailing Address - Fax:
Practice Address - Street 1:3152 N MILLBROOK AVE STE D
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1459
Practice Address - Country:US
Practice Address - Phone:559-241-0364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PANACEA SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-01
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMEDI-CALOther343444000