Basic Information
| Provider Information | |||||||||
| NPI: | 1770722282 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVA SOUTHEASTERN UNIVERSITY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 290250 | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333290250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3301 COLLEGE AVE | ||||||||
| Address2: | ROOM 1441 - UNIVERSITY CENTER | ||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624100 | ||||||||
| FaxNumber: | 9542621788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2009 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | OLLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CLINICAL OOPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9542624343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NOVA SOUTHEASTERN UNIVERSITY, INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
ID Information
| ID | Type | State | Issuer | Description | 886463200 | 05 | FL | MEDICAID |