Provider Demographics
NPI:1124272943
Name:EASTLAND INC.
Entity type:Organization
Organization Name:EASTLAND INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YEVGENY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAKUSILO
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DOM
Authorized Official - Phone:773-271-2991
Mailing Address - Street 1:4856 N DAMEN AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1995
Mailing Address - Country:US
Mailing Address - Phone:773-271-2991
Mailing Address - Fax:773-271-2996
Practice Address - Street 1:4856 N DAMEN AVE
Practice Address - Street 2:STE 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1995
Practice Address - Country:US
Practice Address - Phone:773-271-2991
Practice Address - Fax:773-271-2996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1578841261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center