Basic Information
| Provider Information | |||||||||
| NPI: | 1922550003 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVA SOUTHEASTERN UNIVERSITY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3375 SW 75TH AVE | ||||||||
| Address2: | ROOM 1021 | ||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333141400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624149 | ||||||||
| FaxNumber: | 9542621788 | ||||||||
| Practice Location | |||||||||
| Address1: | 3375 SW 75TH AVE | ||||||||
| Address2: | ROOM 1021 | ||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333141400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624149 | ||||||||
| FaxNumber: | 9542621788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2016 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | OLLER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL ADVISOR | ||||||||
| 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.