=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760157762
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARATHON HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2021
-----------------------------------------------------
Last Update Date | 08/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 FOREST HILL BLVD BLDG E
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33406-5813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-437-6584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 WINOOSKI FALLS WAY
-----------------------------------------------------
City | WINOOSKI
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05404-2228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-857-0400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JEFF WELLS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 802-857-0400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------