Provider Demographics
NPI:1902964174
Name:4TH STREET LASER & SURGERY CENTER INC
Entity Type:Organization
Organization Name:4TH STREET LASER & SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RN CASC
Authorized Official - Phone:707-546-8100
Mailing Address - Street 1:1720 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3602
Mailing Address - Country:US
Mailing Address - Phone:707-546-8100
Mailing Address - Fax:707-544-6438
Practice Address - Street 1:1720 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3602
Practice Address - Country:US
Practice Address - Phone:707-546-8100
Practice Address - Fax:707-544-6438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000344261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01428GMedicaid
CA110000344OtherSTATE OF CA LICENSE
CA110000344OtherSTATE OF CA LICENSE