MEDICARE: ETHAN HEALTH 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1205342748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHAN HEALTH LLC

Provider Business Mailing Address
First Line	:	1623 FOXHAVEN DR
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-1056
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1623 FOXHAVEN DR
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-1056
Country	:	US
Telephone Number	:	859-625-5235
Fax Number	:	859-625-5237

Authorized Official
Title or Position	:	OFFICIAL CREDENTIALING MANAGER
Name	:	JENNIFER EVANS
Credential	:
Telephone Number	:	859-317-8714

Provider Enumeration Date	:	12/20/2017
Last Update Date	:	12/20/2017

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