Provider Demographics
NPI:1326298803
Name:PANACEA ALLIANCE CORP.
Entity Type:Organization
Organization Name:PANACEA ALLIANCE CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ENEIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-342-0672
Mailing Address - Street 1:1750 TREE BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5719
Mailing Address - Country:US
Mailing Address - Phone:904-342-0672
Mailing Address - Fax:
Practice Address - Street 1:1750 TREE BLVD
Practice Address - Street 2:STE 5
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5715
Practice Address - Country:US
Practice Address - Phone:904-342-0672
Practice Address - Fax:904-342-0673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363LF0000X
FLME834442084P0800X
FLME 834442084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04342OtherBCBS
FL002853400Medicaid
FL002853401Medicaid
FLDO1769OtherRR MEDICARE
FL002853401Medicaid
FLAP373Medicare PIN