Organization
CENTER FOR COSMETIC AND LASER SURGERY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JEFFREY S POULTER MD (OWNER)
(309) 663-1222
Entity
Organization
Contact information
Practice address
1505 EASTLAND DR, STE 350, BLOOMINGTON, IL 61701-3534
(309) 663-1222
Mailing address
1505 EASTLAND DR, STE 350, BLOOMINGTON, IL 61701-3534
(309) 663-1222
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
036084126
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036084126
—
IL
Enumeration date
02/06/2013
Last updated
02/06/2013
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