Healthcare Provider Details

I. General information

NPI: 1467627208
Provider Name (Legal Business Name): NICHOLAS D A SUITE MD NEUROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 NW 33RD ST STE 101
HOLLYWOOD FL
33024-2209
US

IV. Provider business mailing address

7900 NW 33RD ST STE 101
HOLLYWOOD FL
33024-2209
US

V. Phone/Fax

Practice location:
  • Phone: 954-431-6884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberME 59343
License Number StateFL

VIII. Authorized Official

Name: NICHOLAS SUITE
Title or Position: PRESIDENT
Credential:
Phone: 954-431-6884