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General NPI Number Information
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NPI Number | 1215276530
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Entity Type | Organization
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Legal Business Name | CENTER FOR COSMETIC AND LASER SURGERY, LLC
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Dates
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Enumeration Date | 02/06/2013
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Last Update Date | 02/06/2013
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Provider Practice Location Address
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Address Line | 1505 EASTLAND DR STE 350
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City | BLOOMINGTON
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State | IL
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Zip | 61701-3534
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Country | US
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Telephone | 309-663-1222
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Fax |
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Provider Business Mailing Address
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Address Line | 1505 EASTLAND DR STE 350
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City | BLOOMINGTON
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State | IL
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Zip | 61701-3534
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Country | US
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Telephone | 309-663-1222
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEFFREY S POULTER
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Credential | MD
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Telephone | 309-663-1222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 036084126
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License Number State | IL
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