Provider Demographics
NPI:1710052766
Name:NOVA SOUTHEASTERN UNIVERSITY, INC
Entity Type:Organization
Organization Name:NOVA SOUTHEASTERN UNIVERSITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICAL OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:OLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-262-4343
Mailing Address - Street 1:PO BOX 290250
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0250
Mailing Address - Country:US
Mailing Address - Phone:954-262-7750
Mailing Address - Fax:954-262-1172
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-7750
Practice Address - Fax:954-262-3987
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVA SOUTHEASTERN UNIVERSITY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-22
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL087386100Medicaid
FL77894AMedicare ID - Type UnspecifiedGROUP NUMBER