Provider Demographics
NPI:1770533390
Name:NOVA SOUTHEASTERN UNIVERSITY INC.
Entity type:Organization
Organization Name:NOVA SOUTHEASTERN UNIVERSITY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING AND CREDENTIALING DIREC
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSEMERY
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTEVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-262-4343
Mailing Address - Street 1:3200 S UNIVERSITY DR BLDG 3
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-4343
Mailing Address - Fax:954-262-3882
Practice Address - Street 1:3200 S UNIVERSITY DRIVE
Practice Address - Street 2:SANFORD L. ZIFF BLDG.
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-7382
Practice Address - Fax:954-262-3882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPNU051291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE9124Medicare ID - Type Unspecified
FLU96570Medicare UPIN