Provider Demographics
NPI:1225626054
Name:ETHOS HEATH TAMPA 5LLC
Entity Type:Organization
Organization Name:ETHOS HEATH TAMPA 5LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-732-5590
Mailing Address - Street 1:4710 N HABANA AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7151
Mailing Address - Country:US
Mailing Address - Phone:352-732-5590
Mailing Address - Fax:352-732-0292
Practice Address - Street 1:4710 N HABANA AVE STE 302
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7151
Practice Address - Country:US
Practice Address - Phone:352-732-5590
Practice Address - Fax:352-732-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty