Basic Information
| Provider Information | |||||||||
| NPI: | 1184137564 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVA SOUTHEASTERN UNIVERSITY INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 290370 | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333290370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624343 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7600 SW 36TH ST | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333281902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624149 | ||||||||
| FaxNumber: | 9542621788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2017 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | OLLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP CLINICAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9542624343 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.