Provider Demographics
NPI:1225840036
Name:ETHOS AT HOME, LLC
Entity type:Organization
Organization Name:ETHOS AT HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
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 1:415 COWART AVE STE E
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2651
Mailing Address - Country:US
Mailing Address - Phone:352-732-5590
Mailing Address - Fax:
Practice Address - Street 1:415 COWART AVE STE E
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2651
Practice Address - Country:US
Practice Address - Phone:352-732-5590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center