# EASTLAND MEDICAL PLAZA SURGICENTER, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1699751289
- **Authorized official:** MRS. JACKIE ANN FRYE (BUSINESS OFFICE MANAGER)
- **Authorized official phone:** (309) 663-1997

## Contact information

- **Practice address:** 1505 EASTLAND DR, BLOOMINGTON, IL 61701-3534
- **Practice address phone:** (309) 663-1997
- **Practice address fax:** (309) 662-9527
- **Mailing address:** 1505 EASTLAND DR, BLOOMINGTON, IL 61701-3534
- **Mailing address phone:** (309) 663-1997
- **Mailing address fax:** (309) 662-9527

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | 7002413 | IL | Yes |

## Other

- **Enumeration date:** 12/16/2005
- **Last updated:** 01/06/2010