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General NPI Number Information
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NPI Number | 1902964174
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Entity Type | Organization
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Legal Business Name | 4TH STREET LASER & SURGERY CENTER INC
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 01/17/2013
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Provider Practice Location Address
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Address Line | 1720 4TH ST
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City | SANTA ROSA
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State | CA
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Zip | 95404-3602
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Country | US
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Telephone | 707-546-8100
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Fax | 707-544-6438
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Provider Business Mailing Address
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Address Line | 1720 4TH ST
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City | SANTA ROSA
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State | CA
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Zip | 95404-3602
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Country | US
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Telephone | 707-546-8100
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Fax | 707-544-6438
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. ELAYNE CLARK
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Credential | RN CASC
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Telephone | 707-546-8100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 110000344
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License Number State | CA
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