Healthcare Provider Details

I. General information

NPI: 1548131253
Provider Name (Legal Business Name): RONDAVIUS MILAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2025
Last Update Date: 09/16/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6848 SAUTERNE CV
MEMPHIS TN
38115-5341
US

IV. Provider business mailing address

6848 SAUTERNE CV
MEMPHIS TN
38115-5341
US

V. Phone/Fax

Practice location:
  • Phone: 901-247-8105
  • Fax:
Mailing address:
  • Phone: 901-247-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number124637783
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: