Healthcare Provider Details

I. General information

NPI: 1902119985
Provider Name (Legal Business Name): NOVA SOUTHEASTERN UNIVERSITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 NE 26TH STREET
WILTON MANORS FL
33305-1239
US

IV. Provider business mailing address

3200 S. UNIVERSITY DRIVE SANFORD L. ZIFF BLDG. 3RD FLOOR, ROOM 4364-D
FT. LAUDERDALE FL
33328-2018
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-1408
  • Fax: 954-262-3217
Mailing address:
  • Phone: 954-262-4343
  • Fax: 954-262-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT S OLLER
Title or Position: CEO/CLINICAL OPERATIONS
Credential: D.O.
Phone: 954-262-4343