Healthcare Provider Details

I. General information

NPI: 1013461243
Provider Name (Legal Business Name): INITIA NOVA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2016
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 MARLTON PIKE E STE H42
CHERRY HILL NJ
08003-4104
US

IV. Provider business mailing address

1930 MARLTON PIKE E STE H42
CHERRY HILL NJ
08003-4104
US

V. Phone/Fax

Practice location:
  • Phone: 856-425-2942
  • Fax:
Mailing address:
  • Phone: 856-425-2942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number37F100176500
License Number StateNJ

VIII. Authorized Official

Name: DR. PATRICK O SULLIVAN
Title or Position: CHIEF MEDICAL OFFICER
Credential: D.O.
Phone: 856-625-8563