Provider Demographics
NPI:1649802570
Name:EYTALIS-MAINS, RYAN GREY (MAT, LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:GREY
Last Name:EYTALIS-MAINS
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7952 SE ASPEN SUMMIT DR APT 150
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-9212
Mailing Address - Country:US
Mailing Address - Phone:907-240-8556
Mailing Address - Fax:
Practice Address - Street 1:909 SW 18TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1705
Practice Address - Country:US
Practice Address - Phone:907-240-8556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer