Provider Demographics
NPI:1912542192
Name:ETHOS HEALTH MARYLAND 4, LLC
Entity Type:Organization
Organization Name:ETHOS HEALTH MARYLAND 4, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
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 1:1411 MADISON PARK DR
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6185
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:2019-11-12
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service