| Ethos Health Tampa 3, Llc | |
|
34754 Us Highway 19 N Palm Harbor FL 34684-2120 | |
| (352) 732-5590 | |
| (352) 732-0292 |
| Full Name | Ethos Health Tampa 3, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 34754 Us Highway 19 N, Palm Harbor, Florida |
| Authorized Official Name and Position | Jonathan Walker (OWNER/OPERATOR) |
| Authorized Official Contact | 3527325590 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Ethos Health Tampa 3, Llc 1541 Se 17th St Ocala FL 34471-4607 Ph: (352) 732-5590 | Ethos Health Tampa 3, Llc 34754 Us Highway 19 N Palm Harbor FL 34684-2120 Ph: (352) 732-5590 |
| NPI Number | 1609368190 |
|---|---|
| Provider Enumeration Date | 05/31/2018 |
| Last Update Date | 06/29/2021 |
| Medicare PECOS PAC ID | 9830593904 |
|---|---|
| Medicare Enrollment ID | O20210811002554 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1609368190 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
| Provider Name | Matthew Shanklin |
|---|---|
| Provider Type | Practitioner - Physical Therapist In Private Practice |
| Provider Identifiers | NPI Number: 1588146443 PECOS PAC ID: 5294070728 Enrollment ID: I20190102001939 |
| Provider Name | Victoria Waechter |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1316512254 PECOS PAC ID: 2466858386 Enrollment ID: I20210901000869 |
| Provider Name | Kyle Jonathon Chacon |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1457839359 PECOS PAC ID: 4183021884 Enrollment ID: I20220225002467 |
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