Healthcare Provider Details

I. General information

NPI: 1164465126
Provider Name (Legal Business Name): EDWARD JAMES LEWIS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NE 48TH AVE SUITE 700
HILLSBORO OR
97124-4904
US

IV. Provider business mailing address

5735 SW 170TH AVE
ALOHA OR
97007-3318
US

V. Phone/Fax

Practice location:
  • Phone: 503-312-2616
  • Fax: 503-693-2330
Mailing address:
  • Phone: 503-681-4260
  • Fax: 503-693-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-142301
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: