Healthcare Provider Details

I. General information

NPI: 1346809290
Provider Name (Legal Business Name): INITIUM NOVUM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1657 N MIAMI AVE APT 515
MIAMI FL
33136-2010
US

IV. Provider business mailing address

1657 N MIAMI AVE APT 515
MIAMI FL
33136-2010
US

V. Phone/Fax

Practice location:
  • Phone: 310-367-7517
  • Fax:
Mailing address:
  • Phone: 310-367-7517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TERRENCE VALENTINO BAILEY
Title or Position: DIRECTOR OF HUMAN PERFORMANCE
Credential: EXERCISEPHYSIOLOGIST
Phone: 310-367-7517