Provider Demographics
NPI:1003559675
Name:PANACEA PORTAL LLC
Entity Type:Organization
Organization Name:PANACEA PORTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-509-4774
Mailing Address - Street 1:6457 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-9303
Mailing Address - Country:US
Mailing Address - Phone:248-509-4774
Mailing Address - Fax:
Practice Address - Street 1:6457 HICKORY LN
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-9303
Practice Address - Country:US
Practice Address - Phone:248-509-4774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty