# 4TH STREET LASER & SURGERY CENTER INC

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

## Provider details

- **NPI number:** 1902964174
- **Authorized official:** MS. ELAYNE CLARK RN CASC (ADMINISTRATOR)
- **Authorized official phone:** (707) 546-8100

## Contact information

- **Practice address:** 1720 4TH ST, SANTA ROSA, CA 95404-3602
- **Practice address phone:** (707) 546-8100
- **Practice address fax:** (707) 544-6438
- **Mailing address:** 1720 4TH ST, SANTA ROSA, CA 95404-3602
- **Mailing address phone:** (707) 546-8100
- **Mailing address fax:** (707) 544-6438

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | 110000344 | CA | Yes |

## Other

- **Enumeration date:** 12/04/2006
- **Last updated:** 01/17/2013