Healthcare Provider Details

I. General information

NPI: 1497295604
Provider Name (Legal Business Name): MARATHON HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18150 MURDOCK CIR BLDG G C/O CHARLOTTE SCHOOLS WELLNESS CENTER
PORT CHARLOTTE FL
33948-4027
US

IV. Provider business mailing address

20 WINOOSKI FALLS WAY STE 400
WINOOSKI VT
05404-2239
US

V. Phone/Fax

Practice location:
  • Phone: 802-857-0434
  • Fax:
Mailing address:
  • Phone: 802-857-0434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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