Provider Demographics
NPI:1316394083
Name:PACIFIC NEURO THERAPY
Entity Type:Organization
Organization Name:PACIFIC NEURO THERAPY
Other - Org Name:APEX PERFORMANCE WELLNESS & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER & PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTRUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-294-2669
Mailing Address - Street 1:11105 SW GREENBURG RD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5446
Mailing Address - Country:US
Mailing Address - Phone:971-294-2669
Mailing Address - Fax:503-746-6609
Practice Address - Street 1:11105 SW GREENBURG RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5446
Practice Address - Country:US
Practice Address - Phone:971-294-2669
Practice Address - Fax:503-746-6609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty