Provider Demographics
NPI:1578975819
Name:ATHLETES' POTENTIAL
Entity Type:Organization
Organization Name:ATHLETES' POTENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS, CSCS
Authorized Official - Phone:478-456-2149
Mailing Address - Street 1:1048 WOODLAND AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2512
Mailing Address - Country:US
Mailing Address - Phone:478-456-2149
Mailing Address - Fax:
Practice Address - Street 1:1730 TAYLOR ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-3742
Practice Address - Country:US
Practice Address - Phone:478-456-2149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty