Basic Information
| Provider Information | |||||||||
| NPI: | 1861795734 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARATHON HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARATHON HEALTH AT DRS NO. BABCOCK | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 354 MOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | COLCHESTER | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054465968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028570400 | ||||||||
| FaxNumber: | 8026553607 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N BABCOCK ST | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329356715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213086323 | ||||||||
| FaxNumber: | 3212532271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2010 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | FORD | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8028570400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARATHON HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 60 4022 | FL | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.