Healthcare Provider Details

I. General information

NPI: 1215153507
Provider Name (Legal Business Name): PACIFIC THERX, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 PORTOLA RD SUITE B
PORTOLA VALLEY CA
94028-7852
US

IV. Provider business mailing address

150 PORTOLA RD SUITE B
PORTOLA VALLEY CA
94028-7852
US

V. Phone/Fax

Practice location:
  • Phone: 650-851-1145
  • Fax: 650-851-9251
Mailing address:
  • Phone: 650-851-1145
  • Fax: 650-851-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT18800
License Number StateCA

VIII. Authorized Official

Name: MS. LISA DIANE GREEN II
Title or Position: CEO
Credential: MPT, ATC
Phone: 650-851-1145