Provider Demographics
NPI:1457313355
Name:METRO ATHLETIC TRAINERS ALLIANCE, AKA MATA
Entity Type:Organization
Organization Name:METRO ATHLETIC TRAINERS ALLIANCE, AKA MATA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC TRAINER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:ATC/R
Authorized Official - Phone:503-312-2616
Mailing Address - Street 1:5735 SW 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-3318
Mailing Address - Country:US
Mailing Address - Phone:503-356-0120
Mailing Address - Fax:503-693-2330
Practice Address - Street 1:5735 SW 170TH AVE
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97007-3318
Practice Address - Country:US
Practice Address - Phone:503-356-0120
Practice Address - Fax:503-693-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATAT142301225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Single Specialty