MEDICARE: INITIAL INNOVATIVE BLOOD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156F00000X	Technician/Technologist

General Provider Information

NPI Number	:	1437736295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INITIAL INNOVATIVE BLOOD, LLC

Provider Business Mailing Address
First Line	:	16481 WATERWAY CIR APT B
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-3256
Country	:	US
Telephone Number	:	714-209-9009
Fax Number	:	714-384-7233

Provider Business Practice Location Address
First Line	:	16481 WATERWAY CIR APT B
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-3256
Country	:	US
Telephone Number	:	714-209-9009
Fax Number	:	714-384-7233

Authorized Official
Title or Position	:	CEO
Name	:	MR. ALFRED SAMUEL
Credential	:
Telephone Number	:	714-209-9009

Provider Enumeration Date	:	03/26/2021
Last Update Date	:	03/26/2021

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