Basic Information
| Provider Information | |||||||||
| NPI: | 1497295604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARATHON HEALTH LLC | ||||||||
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| OtherOrganizationName: | CHARLOTTE SCHOOLS WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 WINOOSKI FALLS WAY STE 400 | ||||||||
| Address2: | |||||||||
| City: | WINOOSKI | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054042239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028570434 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18150 MURDOCK CIR BLDG G | ||||||||
| Address2: | C/O CHARLOTTE SCHOOLS WELLNESS CENTER | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339484027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028570434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2017 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8028570400 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARATHON HEALTH, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.