Provider Demographics
NPI:1770722282
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 OOPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
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:954-262-4100
Mailing Address - Fax:
Practice Address - Street 1:3301 COLLEGE AVE
Practice Address - Street 2:ROOM 1441 - UNIVERSITY CENTER
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314
Practice Address - Country:US
Practice Address - Phone:954-262-4100
Practice Address - Fax:954-262-1788
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVA SOUTHEASTERN UNIVERSITY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-09
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886463200Medicaid