MEDICARE: ETHOS MEDICAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1871051086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHOS MEDICAL LLC

Provider Business Mailing Address
First Line	:	2011 S 25TH ST STE 216
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4753
Country	:	US
Telephone Number	:	772-228-1198
Fax Number	:

Provider Business Practice Location Address
First Line	:	2011 S 25TH ST STE 216
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4753
Country	:	US
Telephone Number	:	772-228-1198
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAY PLUMMER
Credential	:
Telephone Number	:	754-224-0142

Provider Enumeration Date	:	03/06/2019
Last Update Date	:	10/02/2019

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