=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720126584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA SOUTHEASTERN UNIVERSITY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2007
-----------------------------------------------------
Last Update Date | 05/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 COLLEGE AVE UNIVERSITY CENTER ROOM 1433
-----------------------------------------------------
City | FT. LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33314-7721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-262-5590
-----------------------------------------------------
Fax | 954-262-5570
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3200 S UNIVERSITY DR SANFORD L. ZIFF BLDG, 3RD FLOOR, ROOM 4364-D
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-262-4343
-----------------------------------------------------
Fax | 954-262-1172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIR OF CONTRACTING AND CREDEN
-----------------------------------------------------
Name | ROSEMERY ESTEVEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-262-4343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 204D00000X
-----------------------------------------------------
Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------