Provider Demographics
NPI:1215276530
Name:CENTER FOR COSMETIC AND LASER SURGERY, LLC
Entity type:Organization
Organization Name:CENTER FOR COSMETIC AND LASER SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:POULTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-663-1222
Mailing Address - Street 1:1505 EASTLAND DR
Mailing Address - Street 2:STE 350
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3534
Mailing Address - Country:US
Mailing Address - Phone:309-663-1222
Mailing Address - Fax:
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:STE 350
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3534
Practice Address - Country:US
Practice Address - Phone:309-663-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084126208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084126Medicaid