Provider Demographics
NPI:1407146160
Name:NOVRESKE, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:NOVRESKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1020
Mailing Address - Country:US
Mailing Address - Phone:954-467-9019
Mailing Address - Fax:
Practice Address - Street 1:1320 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1020
Practice Address - Country:US
Practice Address - Phone:954-467-9019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 62500225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL677739200Medicaid