Provider Demographics
NPI:1326530817
Name:ETHOS HEALTH TAMPA 4 LLC
Entity Type:Organization
Organization Name:ETHOS HEALTH TAMPA 4 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-732-5590
Mailing Address - Street 1:1541 SE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-4607
Mailing Address - Country:US
Mailing Address - Phone:352-732-5590
Mailing Address - Fax:352-732-0292
Practice Address - Street 1:710 OAKFIELD DR STE 105
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4931
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:2018-05-31
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty