Provider Demographics
NPI:1508315300
Name:PACIFIC THERX
Entity Type:Organization
Organization Name:PACIFIC THERX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:650-851-1145
Mailing Address - Street 1:150 PORTOLA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028-7852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 PORTOLA RD
Practice Address - Street 2:SUITE B
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7852
Practice Address - Country:US
Practice Address - Phone:530-417-7505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291827261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy