Healthcare Provider Details

I. General information

NPI: 1992419709
Provider Name (Legal Business Name): 4TH SECOND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 01/06/2023
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 AMADOR ST
VALLEJO CA
94590-4606
US

IV. Provider business mailing address

839 VALLE VISTA AVE
VALLEJO CA
94590-3542
US

V. Phone/Fax

Practice location:
  • Phone: 707-335-0300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: EMILY FISHER
Title or Position: DIRECTOR OF COMMUNITY HEALTH
Credential: MD
Phone: 530-574-4847