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General NPI Number Information
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NPI Number | 1811085459
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Entity Type | Organization
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Legal Business Name | GASTROINTESTINAL DIAGNOSTIC CLINIC
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Dates
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Enumeration Date | 10/10/2006
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Last Update Date | 10/18/2007
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Provider Practice Location Address
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Address Line | 3196 S MARYLAND PKWY SUITE 207
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City | LAS VEGAS
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State | NV
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Zip | 89109-2305
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Country | US
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Telephone | 702-369-3400
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Fax |
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Provider Business Mailing Address
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Address Line | 3196 S MARYLAND PKWY SUITE 207
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City | LAS VEGAS
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State | NV
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Zip | 89109-2305
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Country | US
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Telephone | 702-369-3400
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Fax |
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Authorized Official
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Title or Position | SENIOR CONSULTANT
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Name | MR. JACK GERARD LONDON
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Credential | MBA/MHA
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Telephone | 702-737-7555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 477ASC-8
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License Number State | NV
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