MEDICARE: ETHOS HEALTH TAMPA 3, 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1609368190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHOS HEALTH TAMPA 3, LLC

Provider Business Mailing Address
First Line	:	1541 SE 17TH ST
Second Line	:
City	:	OCALA
State	:	FL
Zip	:	34471-4607
Country	:	US
Telephone Number	:	352-732-5590
Fax Number	:	352-732-0292

Provider Business Practice Location Address
First Line	:	34754 US HIGHWAY 19 N
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-2120
Country	:	US
Telephone Number	:	352-732-5590
Fax Number	:	352-732-0292

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	JONATHAN WALKER
Credential	:
Telephone Number	:	352-732-5590

Provider Enumeration Date	:	05/31/2018
Last Update Date	:	06/29/2021

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