Healthcare Provider Details

I. General information

NPI: 1316394083
Provider Name (Legal Business Name): PACIFIC NEURO THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11105 SW GREENBURG RD
TIGARD OR
97223-5446
US

IV. Provider business mailing address

11105 SW GREENBURG RD
TIGARD OR
97223-5446
US

V. Phone/Fax

Practice location:
  • Phone: 971-294-2669
  • Fax: 503-746-6609
Mailing address:
  • Phone: 971-294-2669
  • Fax: 503-746-6609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KELLEN MASTRUD
Title or Position: CO-OWNER & PRESIDENT
Credential:
Phone: 971-294-2669