Healthcare Provider Details

I. General information

NPI: 1033412903
Provider Name (Legal Business Name): MARATHON HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 W HIBISCUS BLVD
MELBOURNE FL
32901-2704
US

IV. Provider business mailing address

354 MOUNTAIN VIEW DR SUITE 300
COLCHESTER VT
05446-5968
US

V. Phone/Fax

Practice location:
  • Phone: 321-309-0565
  • Fax: 321-309-0567
Mailing address:
  • Phone: 802-857-0400
  • Fax: 802-655-3607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number60 4021
License Number StateFL

VIII. Authorized Official

Name: MR. JERRY M FORD
Title or Position: CEO
Credential:
Phone: 802-857-0400