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NPI Code Detail

MEDICARE: PACIFIC THERX, INC.

MEDICARE: PACIFIC THERX, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1174400000XSpecialistPT18800CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1ZZZ60919ZOTHERCABLUE SHIELD

General Provider Information

NPI Number : 1215153507
Entity Type Code : Organization
Provider Name (Legal Business Name) : PACIFIC THERX, INC.
Provider Business Mailing Address
First Line : 150 PORTOLA RD
Second Line : SUITE B
City : PORTOLA VALLEY
State : CA
Zip : 94028-7852
Country : US
Telephone Number : 650-851-1145
Fax Number : 650-851-9251
Provider Business Practice Location Address
First Line : 150 PORTOLA RD
Second Line : SUITE B
City : PORTOLA VALLEY
State : CA
Zip : 94028-7852
Country : US
Telephone Number : 650-851-1145
Fax Number : 650-851-9251
Authorized Official
Title or Position : CEO
Name : MS. LISA DIANE GREEN II
Credential : MPT, ATC
Telephone Number : 650-851-1145
Provider Enumeration Date : 04/17/2007
Last Update Date : 08/22/2020

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