Provider Demographics
NPI:1851177265
Name:PANACEA PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PANACEA PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:MOUSTAFA
Authorized Official - Last Name:SHARAF
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:860-726-8163
Mailing Address - Street 1:115 ELM ST STE 208
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3735
Mailing Address - Country:US
Mailing Address - Phone:860-726-8163
Mailing Address - Fax:
Practice Address - Street 1:115 ELM ST STE 208
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3735
Practice Address - Country:US
Practice Address - Phone:860-726-8163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation