Healthcare Provider Details

I. General information

NPI: 1457313355
Provider Name (Legal Business Name): METRO ATHLETIC TRAINERS ALLIANCE, AKA MATA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5735 SW 170TH AVE
ALOHA OR
97007-3318
US

IV. Provider business mailing address

5735 SW 170TH AVE
ALOHA OR
97007-3318
US

V. Phone/Fax

Practice location:
  • Phone: 503-356-0120
  • Fax: 503-693-2330
Mailing address:
  • Phone: 503-356-0120
  • Fax: 503-693-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License NumberATAT142301
License Number StateOR

VIII. Authorized Official

Name: MR. EDWARD JAMES LEWIS
Title or Position: ATHLETIC TRAINER
Credential: ATC/R
Phone: 503-312-2616