Provider Demographics
NPI:1033412903
Name:MARATHON HEALTH, INC.
Entity Type:Organization
Organization Name:MARATHON HEALTH, INC.
Other - Org Name:MARATHON HEALTH AT DRS W. HIBISCUS
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-857-0400
Mailing Address - Street 1:354 MOUNTAIN VIEW DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-5968
Mailing Address - Country:US
Mailing Address - Phone:802-857-0400
Mailing Address - Fax:802-655-3607
Practice Address - Street 1:1110 W HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2704
Practice Address - Country:US
Practice Address - Phone:321-309-0565
Practice Address - Fax:321-309-0567
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARATHON HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60 4021332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site