Provider Demographics
NPI:1215153507
Name:PACIFIC THERX, INC.
Entity type:Organization
Organization Name:PACIFIC THERX, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:II
Authorized Official - Credentials:MPT, ATC
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:650-851-1145
Mailing Address - Fax:650-851-9251
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:650-851-1145
Practice Address - Fax:650-851-9251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ60919ZOtherBLUE SHIELD
CAZZZ19256ZMedicare ID - Type Unspecified