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General NPI Number Information
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NPI Number | 1619848033
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Entity Type | Organization
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Legal Business Name | INITIUM VITAE
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Dates
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Enumeration Date | 09/17/2025
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Last Update Date | 09/17/2025
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Provider Practice Location Address
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Address Line | 6254 WARM SPRINGS RD APT D6
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City | COLUMBUS
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State | GA
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Zip | 31909-9144
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Country | US
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Telephone | 470-652-1202
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Fax | 706-671-6317
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Provider Business Mailing Address
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Address Line | 6254 WARM SPRINGS RD APT D6
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City | COLUMBUS
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State | GA
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Zip | 31909-9144
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Country | US
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Telephone | 470-652-1202
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | DESHAUN INGERSOLL-BROWN
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Credential |
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Telephone | 470-815-1138
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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