Healthcare Provider Details

I. General information

NPI: 1093376840
Provider Name (Legal Business Name): MARATHON HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHEROKEE DR STE 5
MARSHALL MO
65340-1690
US

IV. Provider business mailing address

PO BOX 5
WINOOSKI VT
05404-0005
US

V. Phone/Fax

Practice location:
  • Phone: 660-202-4227
  • Fax:
Mailing address:
  • Phone: 802-857-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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