Provider Demographics
NPI:1992038152
Name:JACK ANSTANDIG MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JACK ANSTANDIG MD PROFESSIONAL CORPORATION
Other - Org Name:BODYLOGICMD OF LAS VEGAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANSTANDIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-972-5182
Mailing Address - Street 1:8475 S EASTERN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-2862
Mailing Address - Country:US
Mailing Address - Phone:866-972-5182
Mailing Address - Fax:866-972-5183
Practice Address - Street 1:8475 S EASTERN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-2862
Practice Address - Country:US
Practice Address - Phone:866-972-5182
Practice Address - Fax:866-972-5183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty