1669791646 NPI number — PANACEA GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669791646 NPI number — PANACEA GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PANACEA GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669791646
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3786 LA CRESCENTA AVE
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91208-1055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-243-0010
Provider Business Mailing Address Fax Number:
818-243-0011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3786 LA CRESCENTA AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91208-1055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-243-0010
Provider Business Practice Location Address Fax Number:
818-243-0011
Provider Enumeration Date:
05/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KARIMIAN
Authorized Official First Name:
SIMON
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
818-243-0010

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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