Provider Demographics
NPI:1619848033
Name:INITIUM VITAE
Entity type:Organization
Organization Name:INITIUM VITAE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DESHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:INGERSOLL-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-815-1138
Mailing Address - Street 1:6254 WARM SPRINGS RD APT D6
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-9144
Mailing Address - Country:US
Mailing Address - Phone:470-652-1202
Mailing Address - Fax:
Practice Address - Street 1:6254 WARM SPRINGS RD APT D6
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-9144
Practice Address - Country:US
Practice Address - Phone:470-652-1202
Practice Address - Fax:706-671-6317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-17
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center