Provider Demographics
NPI:1770827917
Name:NOVAL MEDICAL SERVICES, CORP
Entity Type:Organization
Organization Name:NOVAL MEDICAL SERVICES, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICODEMO
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:305-264-0124
Mailing Address - Street 1:300 NW 86TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3894
Mailing Address - Country:US
Mailing Address - Phone:305-264-0124
Mailing Address - Fax:
Practice Address - Street 1:300 NW 86TH PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-3894
Practice Address - Country:US
Practice Address - Phone:305-264-0124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-11
Last Update Date:2012-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9101023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty