Provider Demographics
NPI:1346809290
Name:INITIUM NOVUM LLC
Entity Type:Organization
Organization Name:INITIUM NOVUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HUMAN PERFORMANCE
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:VALENTINO
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:EXERCISEPHYSIOLOGIST
Authorized Official - Phone:310-367-7517
Mailing Address - Street 1:1657 N MIAMI AVE APT 515
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-2010
Mailing Address - Country:US
Mailing Address - Phone:310-367-7517
Mailing Address - Fax:
Practice Address - Street 1:1657 N MIAMI AVE APT 515
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-2010
Practice Address - Country:US
Practice Address - Phone:310-367-7517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or Welfare
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty