Basic Information
| Provider Information | |||||||||
| NPI: | 1629601695 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARATHON HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5 | ||||||||
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| City: | WINOOSKI | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054040005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028570400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10430 RAY RD | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320818813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046718329 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2020 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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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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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.