MEDICARE: ETHOS HEALTH DAYTONA, 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	:	1780176263
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHOS HEALTH DAYTONA, 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	:	325 N WILLIAMSON BLVD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-8171
Country	:	US
Telephone Number	:	352-732-5590
Fax Number	:	352-732-0292

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	JONATHAN RAY WALKER
Credential	:	DC
Telephone Number	:	527-325-5903

Provider Enumeration Date	:	05/31/2018
Last Update Date	:	09/03/2021

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